“Every Intern makes mistakes. The important thing is to neither make the same mistakes twice, nor to make a whole bunch of mistakes all at once.”
—Samuel Shem, “House of God: The Classic Novel of Life and Death in an American Hospital.”
It’s July. Our 2019-2020 academic year has officially started, and my days in the emergency department are spent with our new interns and newly matriculated senior residents.
I’ve been thinking a lot about residents and my time spent as a trainee lately. Mostly this stems from the fact that I am having a harder and harder time identifying with my former self, and I’m trying not to let the memory of my experience fade. Each year it seems that I am becoming increasingly forgetful of the pain and trauma. The wounds heal and it becomes almost impossible to go back mentally or emotionally. The upside is that I don’t re-live it, but the downside is that I can’t identify with those I am trying to teach.
Right now, I am far enough out to critically look at the unique stressors and emotions that were present at the time, but I am still close enough that I haven’t forgotten.
I began my residency in 2003, sixteen years ago. It seems like such a long time has passed, but I find that if I try, the memories are still very vivid. If I try, I can rewind my life and all of the feelings come rushing back. All the suffering, the misery.
I have pushed it away for so long, but I think it is time to examine those emotions a bit. Not only for me, but for all my trainees. We as attendings need to remember what it was like, how hard it is, so we can be more compassionate towards those coming behind us.
Pressure –There is so much pressure. Medical school is challenging, lots of studying, lots of time spent, but as a student you can choose how much and when you will study. The amount of effort you put in determines your grade. As a resident, things are different. The rules that guide us through this time are very strict and it starts with the Match. Upon participating in the nationwide system that places each of us in a residency, you are signing a contract. You are required to show up to the place you matched in June of your graduating year, for a start date of July 1. All over the country, thousands of new doctors are relocating, showing up at their new places of work, right on time and ready to go.
I moved from Kansas City to Connecticut in the summer of 2003. Before residency applications, I had never even been to Connecticut. Fortunately, my mom was willing and able to join me on my trek east. We loaded up my car, shipped about 25 boxes to my new address, and drove. On arrival in my new city, I had 2 days before I was supposed to be at the hospital. We went to Target and Macy’s, bought everything for my apartment. When I went to work, my mom settled me in. She put curtains on my windows and unpacked most of my boxes, so I could find my dishes and get ready in the morning.
There is no wiggle-room, no compromise. The dates are carved in stone, as are the times and the schedule. You must do what you are told to do. You are given a salary, the same as everyone else. You feel like a slave to the system, and it is suffocating.
Judgement—Upon arrival at this new job of residency, you feel like you are trying to prove to everyone that you are smart and capable enough to be there. No one knows you, and so it feels like every day, every interaction with an attending you have never met before, a nurse or a fellow resident, you are being judged. You do not want to be labeled ‘the dumb resident who doesn’t know how to order Tylenol correctly.’
I learned very quickly not only that I was constantly being graded, criticized, and scrutinized, I was also learning to apply the same principles to others. Even though I was supposed to be learning how to be a good doctor, I felt as though I was being judged as though all of it was already taught to me. It felt like there was no room for error. On my first shift in the ER, the attending rolled his eyes at me when I tried to present a patient and I wasn’t sure what to do. It was a case I had never seen before, but with his body language and condescension, I felt inadequate for not knowing. I learned to fake it and pretend as though I didn’t see the eye roll, or the obvious looks of disdain.
Exhaustion—I was tired all the time. Residents work so hard. When I started my residency, they had just passed laws governing how long we could safely work (limited to 30 hours in a row in 2003) and how many hours we could work in a week (80 hours). Coming from medical school, you know the work hours are arduous, but haven’t had to actually work like a resident month after month. Our bodies and minds aren’t quite ready for the massive shift in work that is required. And then there is no real time for rest. Work weeks are 6 days long with one full weekend per month off. We would get two weeks of vacation a year. It’s dizzying.
I distinctly remember walking to my car after one really long and busy call night. I was so tired, and feeling like a failure. On rounds that morning, when asked a question about the differential diagnosis of a patient I had admitted the night before, I stumbled. I remember feeling my face go red with embarrassment as my mind went blank. Then, in front of everyone, I was reprimanded for my lack of knowledge and preparation. I wanted the floor to swallow me whole.
That afternoon, I got to the parking garage and couldn’t remember where I parked 30 hours before. My pungent, tired and emotionally-drained self, broke. I walked through the parking garage that day crying wet hot tears of frustration until I finally found my car and drove myself home. I went back to work the next day and just kept going. You start to forget that life exists outside of this never-ending cycle of long days, little time off. You do really start to eat, sleep and breathe the hospital. There is no other way.
Fear—My residency was in Pediatrics, so upon starting my intern year, I was now responsible for taking care of children. CHILDREN. I was 24 years old and felt as though I had no idea what I was doing. I was terrified of everything, but most specifically of hurting a child. I was worried I wasn’t good enough, that people would think I was stupid or that I shouldn’t be there (enter imposter syndrome).
One night in the Pediatric Intensive Care Unit, I was the senior resident on call. During those months, back in the early 2000s, the attending physicians did not sleep in the hospital, they stayed at home and we would call them for advice. I remember I had a patient one night, by myself, who had rising intracranial pressure. I was trying to medically manage her, but nothing was working, and her pressures kept climbing.
Although I wanted to run and hide, to walk out of the ICU, I stood at the edge of her bed, praying that she wouldn’t die while I waited for my attending to get there. I don’t think I had ever been more scared in my life. Fear seemed to accompany me like a friend, always there, but only making an appearance when things got really bad.
Grief—Working long hours in a hospital comes with it many patient stories, some good, some horrifically awful, but it feels like there is always sadness. Hospitals aren’t really happy places anyway, but in residency it feels like we operate under a cloud of grief. There is just not enough mental space to process everything. I think that grief gets processed last and the least, because it is the hardest.
Death is ever-present and we all remember the first patient we have that dies. Mine was a baby. The baby contracted herpes at birth and over the course of a few days went into multi-organ system failure. I watched as his little body became bloated with fluid as we tried everything in our power to reverse what the virus was doing. After he died I didn’t know how to grieve. I also didn’t have time to grieve, but I was overwhelmed by the sadness I felt by my inability to save him, but also by having to watch him die.
No soft place to land—Looking back, I think this is the hardest. I didn’t have a good support system. I was single, so I didn’t have a partner to talk to. My parents are non-medical, and lived 3000 miles away, so they didn’t understand what I was going through. I had co-residents, but I think we were all trying to survive ourselves. We could commiserate with one another, but none of us was capable of providing the amount of support we each needed individually. The system isn’t forgiving, and that can leave all residents (particularly the soft-hearted ones) feeling abandoned. We have such desires to heal and help and cure, but when we don’t have space to learn from all the experiences we have, we become detached, despondent, and can suffer mental illness ourselves.
My last thought is that I am astonished that I made it, that I had enough resilience to get through.
For the newly minted resident—it gets better. You are enough, and you are a resident because you were smart enough to get there. Your job now is to grow and learn.
I want to remind myself and all of my colleagues that residency is hard. It is unforgiving and emotional. DO any of you have experiences from residency that you would like to share?
Next time, how we can be better as attendings for our trainees.