I recently started my third year (out of four) in medical school at NCNM. Third year is where the transition from student to doctor officially begins, with the start of the internship. It’s finally my opportunity to interact with real patients and start applying all of the knowledge that’s been smashed into my head over the past couple of years. It’s exciting and new. Inspiring and important.
The reality of this transition, however, is a little less glamourous. Essentially, when I went to sleep on the Sunday before my first day of third year, I was a successful and competent student, a highly skilled test-taker, an accomplished massage therapist. But when I woke up on Monday morning, I was a terrible, incompetent doctor.
A friend gave me an inspiring quote that addressed my feelings perfectly: “Dude, sucking at something is the first step towards being sorta good at something.” I totally agree but there’s nothing I hate more than being bad at things.
I am starting out as a Secondary Intern. At my school, as far as I can tell, it goes something like this: At the top, there’s the Attending Physician. That’s the doctor in charge of everything. No decisions can be made without the blessing of the Attending. And if the patient somehow spontaneously explodes during the appointment, regardless of who actually messed up, it’s the responsibility of the Attending and they don’t take this responsibility lightly.
Then there’s the Resident. This is another real doctor, but they’re pretty fresh out of school. They are the Attending’s right hand. The Resident is also very much in charge, but yields to the Attending. If a patient explodes, while the Attending is ultimately responsible, the Resident isn’t totally out of the woods.
Then the Primary Intern. This is a fourth year student. They’re close to graduation. The Primary is expected to be nearly self sufficient as a doctor and act as the main contact with the patient. They try to come up with the diagnosis and treatment plan, but consult with the Attending and Resident before anything is presented to the patient. If a patient explodes, it’s likely the Primary’s fault. It’s the job of the Attending and Resident to make sure this doesn’t happen.
And then there’s me, the Secondary Intern. Secondaries are third year students having their first clinical experience. The main job of a Secondary is to simply learn while making sure to not mess anything up. Stay out of the way. Let the important people do their important things. Maybe take vitals and do little odds and ends. If a patient explodes, everyone will ignore the Secondary, who will be weeping in the corner, convinced that it was their fault.
Secondaries are thankfully ignored and left to observe for the most part, except when the Attending suddenly looks at them and asks a question that is seemingly unrelated to anything going on in the room.
“This is delicious coffee. Much better than Starbucks. You, Secondary, what’s the most common cause of hypothyroidism?”
It seems to be an unwritten rule that before you correctly answer any question, you have to stare at the Attending for a second with a look of horror on your face, then say “Umm…” and then state the answer with a shaky voice and an inflection at the end of the word which implies that you’re completely unsure of yourself. I’m not one to break unwritten rules.
With all of this in mind, I went into my first shift with the simple goal of being the best Secondary who’s ever lived. I want every patient I see to suddenly feel better, my mere presence making diseases vanish. I want to impress everyone so much that they allow me to graduate early and pay off my student loans for me. You know, normal, reasonable goals.
My first shift was at a clinic I’ve never been to before. This added to my nervousness, but the first two hours of the shift were blocked off for an orientation and I was confident that it would help to calm me down. I walked into the clinic and met the Attending, Resident, Primaries and other Secondaries I’d be working with for the next 12 weeks.
As the orientation started, I was excited to have all of my burning questions answered. Things like, “What exactly is expected of me?” And, “Where are the bathrooms?”
But I quickly realized that this orientation was not for me at all. This clinic had recently gone through a complete policy and procedural overhaul and the orientation was mostly to inform the Attendings and Residents about these changes. The new ways to chart and code for screening exams, how to account for the vaccines used, the new policy for ordering labs, and other various things that completely overwhelmed me and made me feel inadequate.
After the orientation, I pulled myself up to a computer so I could access the electronic health record of the first patient I was going to see. I wanted to know everything about her so I could be totally prepared for the encounter and impress everyone with my knowledge of the case. We use a program called “Epic” and the biggest concern with programs like this is patient confidentiality. It’s very tightly regulated and monitored. Everyone has their own login and password they have to use to access any patient information.
I typed my login information, clicked ‘enter’ and a message popped up that said, “the username and/or password is incorrect.” I tried again. Wrong. I tried again. Wrong. A new message popped up that said, “You have exceeded the maximum amount of login attempts.”
I locked myself out of the program. It’s not really a big deal. It happens. All I had to do was speak to the Epic coordinator, but she left for the day. I couldn’t access any charts for the entire shift.
I walked into the first patient’s room with the Primary and all I knew was that this was a returning patient who had recently been seen for painful and debilitating spasms in her low back that traveled down her legs. The Primary had seen this patient before and knew her complete history. They started a discussion about her neck pain. I had no idea what was going on.
I sat quietly while they talked and I occasionally nodded as though I had some understanding of what was happening, which I didn’t. Eventually, the Primary turned to me and said, “Can you take her vitals, please?”
Oh hell yeah! I can do this! Everybody stand back! Prepare to be amazed!
I cleared my throat and calmly said, “Yes, sir.”
The only thing I knew for certain that I’d be doing as a Secondary was taking vitals, so I made sure I had tons of practice. It takes very little, if any skill at all, but it’s definitely not something that should be messed up. I’d spent plenty of time getting comfortable with all the equipment. I could handle a blood pressure cuff like a champion. I could grab that Welch Allyn digital oral thermometer and twirl it around like a cowboy walking out to a duel at high noon. It’s my time.
I stood up and looked for the trusty Welch Allyn oral thermometer. It wasn’t there. Instead, I found a Welch Allyn ear thermometer that I’d never seen before. I’ve never been more afraid of a thermometer. Using one of these things is totally intuitive and easy to figure out. It would take no more than 10 seconds to completely master it, but I absolutely did not want my first actual patient interaction to begin with me standing there for 10 seconds with a confused look on my face while trying to figure out how to use a stupid thermometer, so naturally, I pretended I knew what I was doing.
I fumbled around while trying to figure out how to attach the plastic hygienic cover and when I did, I instinctively put the thermometer directly in her ear. The oral thermometers automatically turn on, so there are no buttons to push before taking the temperature. The ear thermometers, however, do not automatically turn on. I realized this almost immediately, but I’d already jammed the stupid thing into her ear. In an attempt to make my actions appear deliberate, I calmly stood there for a few seconds with the thermometer sitting lifelessly in her ear. Then I took it out and looked for the ‘on’ button while pretending to look at the temperature. I found the button, pushed it and said, “I’d like to check that one more time,” and put it back in her ear.
98.2 degrees. Success! I was sweating, shaking, hyperventilating and possibly speaking in tongues, but I got through it. I finished the rest of the vitals and sat back down with soaking wet armpits.
The Primary began palpating (feeling) and massaging the patient’s neck. He knew I was a massage therapist from an earlier discussion and said, “Would you like to work out some trigger points in her neck while I leave the room to consult with the doctor?”
“Umm…Ok?” I said, remembering to follow the unwritten rules.
He left and I began massaging the patient’s neck. We started chatting and I quickly got comfortable. I explained one of my favorite massage techniques and she agreed to let me try it. She said, “Hmm, that’s very interesting, no one has ever worked on me like this before.”
After a few minutes, the Primary came back and said, “How did James do?”
“I don’t know. He really did something to me while you were gone…” Then she proceeded to inaccurately explain to the Primary what I did while he glared at me with Superman laser-beam eyes that burnt right through my skull. She eventually went on to say that, while it was different, she may have actually liked the technique I used. But the damage was already done, the lesson already learned and the laser-beam burn holes already etched into my skull.
I was reminded that I’m not an accomplished massage therapist anymore, I’m a terrible doctor. My explanation of the technique I used was obviously not clear to the patient and I shouldn’t have said or done anything without explicit directions from someone above me.
The patient left with her treatment plan, feeling better than when she came in, which is always the goal, and I followed the Primary back to the conference room with my tail between my legs, convinced that I was not cut out to be a doctor.
The conference room was bustling with doctors and students talking about various patients and when we came in, everyone stopped and our Attending looked at us and said, “Can we have the secondary present your case to us?”
I knew I couldn’t do it. I thought she was coming in for low-back pain and we focused on her neck. I had no idea what her treatment plan was. I didn’t know if she had a diagnosis. I didn’t even really know her chief complaint. I couldn’t access her chart. How could I possibly give a coherent presentation on her case?
I instantly decided that I was finished feeling inadequate. I am confident. I’m extremely educated. I have massive potential. I am going to be an amazing doctor someday but I’m definitely not there yet and in that moment, I decided I was content with that fact.
I rebelliously broke the unwritten rules. I confidently looked the Attending in his eyes and said, “I don’t feel confident presenting because I don’t think I have a thorough understanding of the patient’s whole story.”
He nodded. “That’s perfectly alright. Let’s have the Primary present then.” The Primary presented and we moved on.
I was assigned to another Primary to see another patient. It was a new patient and there was no prior history that we were expected to know. Walking into the room, the Primary and I had the same amount of information on the patient. I intently listened while the Primary asked questions and conversed with the patient. I nodded when I thought a relevant point came up and was excited and impressed when the Primary asked a smart question. I was following the story and began developing my own ideas about what the diagnosis and treatment might be. I was excited to be a part of this process.
In the middle of this long discussion, the patient stopped, looked over at me and asked, “Are you the doctor?”
I realized that I wasn’t shaking or sweating or hyperventilating. I was listening and thinking. I was engaged and confident. And dammit, I looked like a doctor! “Oh, gosh no. I’m still a student. I don’t think you’d be very happy if I was your doctor at this point.” She smiled.
The primary asked me to take her vitals while she left to consult with the Attending. She left and I stood up to grab one of the two Welch Allyn thermometers that I was now able to use like a champion. Neither was there. All I found was a digital forehead thermometer that I’ve never used before. Unbelievable. I smiled. No more feeling inadequate.
“I’m sorry. I need a second to figure this out. I apparently can’t keep up with the technology these days. Have you ever seen one of these before?” I said while finding the right buttons to push.
She smiled and said, “No. It kind of looks like a mind-erasing machine.”
“Hmm. I don’t think that’s what it does. Let’s find out!” She laughed as I gently pressed it against her forehead. It beeped and showed me a temperature. “Great. If you don’t mind, I’d like to do that one more time to make sure I didn’t make a mistake.” I did it again and got the same reading.
I finished the vitals, the Primary came back and we wrapped up the appointment. The patient left feeling happy about her treatment plan. We made our way back to the conference room and the Attending quickly looked at me, then asked the Primary to present the case. He seemed to know that I’d been through enough for my first day. I think I could’ve done it, but I greatly appreciated his silent mercy. I don’t expect him to let me off so easily in the future.
My first day of seeing patients eventually ended and I can confidently say that it’s official: I am a terrible doctor. But that’s totally ok. I still have almost two years of school left. I’m supposed to be a terrible doctor right now. I just have to make sure that I’m a little less terrible every time I see a patient. I suck, but that’s the first step towards being sorta good. I’m on the right track. The only things that are truly expected of me are authenticity and an honest effort to learn from every experience. I can do that.
The next morning, I had my password reset by the Epic coordinator. Apparently, I’m not the only defeated Secondary to come crawling into her office after getting locked out of the program and she has her own small way of making us feel a little better about it. She gave me a temporary password to gain access to my account: Smile!321. I smiled, thanked her and left her office feeling prepared.
I’m ready for more. I’m ready to learn. I’m ready to confidently present cases. I’m ready to get better every day. I’m ready to make constant mistakes and I’m ready to learn from each one. And I think I’ve figured out all of the thermometers I’m likely to come across. Except a rectal thermometer. Maybe I should practice that one, just in case.