Intern Year: A Resident’s Reflections and Advice

I’m obviously a big fan of reflective writing and of “advice columns.” So, when I got a submission that combines the two genres, and was written by an internal medicine resident, it was impossible not to share.

Adam Cifu

Medical students around the country recently celebrated the annual tradition of Match Day, where graduating students learn where they have “matched” for their residency training. Their residency program is where these soon-to-be physicians will spend the next 3-7 years, honing their craft through rigorous and round-the-clock patient care.

Over these years, these young men and women will be challenged working long hours, bearing witness to how the title “resident” originated. They will be the first to be called/paged/alerted when something goes wrong on the medical wards. They will be reprimanded by disgruntled attendings, sometimes for circumstances out of their control. They will be doused by every type of bodily fluid. Through study and direct experience, they will confront the nuances, surprises, and tragedies of human illness. They will welcome new life into being, and be called to pronounce the deceased. They will meet patients who will leave a mark on their soul. Through it all and with time, the young resident fundamentally changes into a different type of person altogether. Residency training is a journey of a thousand miles, with the very first step taken on that fateful day in March.

And how could this process be anything less than transformational? It is, after all, the most profound vulnerability of the human condition that medicine seeks to address — that of injury, disease, and death. In the grip of such vulnerability, patients seek trustworthy advocates that they can turn to for help. And while learning is life-long, it is in residency training that the aspiring clinician first acquires the techne of medical practice.

Residency is also a time of moral and ethical formation. Technical skills are necessary but not sufficient to practice medicine well. Human illness cannot be reduced to an abnormal lab value or scan — and medicine is not purely mechanistic. Human illness is experiential. It has been said:

“Every form of illness also causes suffering. Most cause us to suffer both physically and psychologically. All of them create spiritual suffering, since they reveal, sometimes with a certain cruelty, the fragile nature of our condition…from this perspective, illness poses a number of inescapable questions: Why? Why me? Why now? For how long? What is to become of me?

Without a doubt, some of these metaphysical questions lie beyond the purview of the physician. But for anybody who has been a patient or accompanied a loved one who is ill, it is clear that empathy, compassion, and honesty matter just as much as clinical acumen. This is evident in research on the patient experience, and something most of us can easily intuit. Every resident lucky enough to work with a truly master clinician will learn from them. But every resident will also, in instances that stand out much more clearly in their memory, work with a physician who truly practices the art of medicine. And it is not any particular medical decision at the moment that stands out, but the orientation of the doctor towards her patient. They will feel something that cannot be explained in technical language, and in many ways it will remind them of what drove them to pursue medicine in the first place.

Unfortunately, residency training brings with it distractions—prioritization of efficiency, the so-called “hidden curriculum”, and systemic barriers—all of which can obfuscate the true focus of the physician’s practice, the patient. This has been described in the literature as moral injury or moral erosion. Therefore intentional practice, guided by mentors whom one wishes to emulate, is of paramount importance.

As a rising PGY-3, I am still a relative novice with much left to learn. With this in mind, I hope to humbly reflect on a few key habits that may be helpful to incoming interns. Many are perhaps self-evident and the list is far from exhaustive.

Emulate

You will work with physicians whose practice inspires you. Write down key behaviors and traits that you observe and then strive to emulate these in your own practice. Also document behaviors you hope to avoid. In the hurry of the day we can often enter “auto-pilot” mode, and neglect reflecting on our own practice patterns.

Check on colleagues

Despite the demands of residency, life continues outside of the hospital. Some of your co-residents will deal with personal struggles. Check in on your colleagues and offer your support (even for those who are not your close friends). It may seem awkward, but it will be appreciated and is the right thing to do.

Avoid gossip

While some decisions in medicine are clear-cut (and you should always intervene if patient safety is at stake), medicine can be highly nuanced and often any number of management decisions can be correct at a given time. Do your best to avoid the temptation to “Monday-morning quarterback” or critique your colleagues publicly. This is poor form and unfair when it happens.

Journal

Log interesting patient cases. More importantly, log your diagnostic oversights, atypical patient presentations, or any other learning points for posterity.

Trust the process

If you haven’t felt imposter syndrome before, you will during intern year. This is normal and expected. Just keep giving your all to your work and you will get to where you need to be.

Little things matter

I once had a clinic patient who had been seen previously several times for a vague abdominal complaint. She appeared upset, and set the tone of our appointment by immediately voicing her displeasure with how her symptoms had been managed. After taking a thorough history and performing a full physical examination, her demeanor changed. At the very end, she exclaimed, “you're the first doctor to really, fully examine me”. Although the ultimate treatment options I offered were no different than prior, she ended up joining my panel and became a patient whom I now see regularly. Do not underestimate how perceptive patients are with regard to the little things—particularly how much care and genuine effort you put into addressing their concerns. Sometimes, this can be demonstrated by something as simple as a thorough physical exam.

Enjoy the journey

The adage that “the days are long, but the years are short” is true. The road will be tough, but set aside moments to reflect and commend yourself on how far you’ve come. In training as physicians we have the privilege of joining a beautiful tradition, refined over millennia, and experience humanity in a way that very few people do.

Yianni Kournoutas is a resident in internal medicine.