Training May Be OverThe Boston Globe | July 3, 2013

By Kiran Gupta

Recently, during one of my last shifts as a resident, I was supervising my intern as we admitted a middle-aged man, Mr. S, who had been transferred from another hospital. His history was complex, the diagnosis unclear. His wife handed us a thick stack of radiology reports, lab test results, and physician notes. For the moment, Mr. S appeared stable, breathing comfortably on supplemental oxygen from a mask. We had time to examine him, go through the records, and think about his symptoms.

As I stepped out of his room, his wife pulled me aside. Her face was taut, exhausted with worry. “Aren’t you both trainees?” she asked, gesturing toward my intern. “I’d really prefer that we see the doctor in charge, not someone still in training.”

It’s not uncommon for patients and their family members to arrive at a hospital like ours expecting to be met by a highly specialized physician with years of experience, even in the middle of the night. When they learn that the initial assessment will be performed by interns and residents, as is standard in most large academic medical centers, their disappointment is palpable. I reassured Mrs. S that the attending rheumatologist and pulmonologist would see her husband in the morning, but that we were the only physicians available right now, and it was essential that we evaluate her husband, as we would any patient under our care. She seemed to hesitate. “Okay,” she said. “But I don’t want you to learn or practice anything on him. Just take care of him and make sure the real doctors come first thing in the morning.”

I have now completed my clinical training, at least in the formal sense. As an attending physician, the idea that others will suddenly perceive me as having all the answers makes me a bit uneasy. While the end of residency was marked in black and white on my calendar, internally the transition feels much more gray. Perhaps my patient’s wife was being overly simplistic in her distinction between those of us in training and the “real doctors” out there. The practice of medicine is after all a life-long learning process that provides constant opportunity for growth, no matter how seasoned a clinician may be. At least, that’s what my mentors tell me.

And yet, there is something special about the experience known as “residency.” As I sat down with my first-year colleague to discuss our patient, I was reminded of that initial “intern” year. I watched as she responded to her incessantly beeping pager, juggled phone calls with consultant specialists, and simultaneously typed notes in the computer system, calmly multi-tasking as we discussed which tests to order and what the diagnosis might be. At one point, she broke off in mid-sentence to exchange a rapid back-and-forth with a nurse about a complicated patient she was monitoring. A few minutes later, she left me at the computer to dash off and check another patient’s blood pressure. Intern year is a chaotic whirlwind, a trial by fire, and one of the most formative experiences in medical training.

At my residency program’s graduation ceremony a few weeks ago, barely three years after we arrived as interns, I remembered Mrs. S’s concerns about being treated by trainees. The truth is that we are all pursuing paths that require us to be life-long learners. In the auditorium where we received our diplomas, portraits of medical luminaries looked down upon us from gilded frames, physicians whose contributions to the field of medicine are legendary. If they had believed they knew it all when they completed residency, we wouldn’t know their names today.

As a graduation gift, we also received a copy of a physicians’ guide written in 1940 by Soma Weiss, former physician-in-chief at Brigham and Women’s Hospital. In the opening, Weiss writes: “To become a good physician one must acquire the habit of caring for patients with a keen mind, and with good judgment, tact and sympathy. To these abilities must be added hard work and a willingness to give one’s self. Without these attributes one cannot become a good physician; with them it is still difficult.”

Reflecting on these words, I am reminded of my colleagues’ camaraderie and support over the past three years. When else in life would I be able to find a dozen familiar faces working alongside me, at any time of day or night, friends with whom to think through a diagnosis or rush to a patient’s bedside to discuss an important exam finding? In their presence, interminable nights that might have seemed a slog became much less daunting—and a lot more fun. I am grateful, too, to my mentors for their fount of medical knowledge, lessons in bedside manner, and unending enthusiasm for clinical medicine. Most importantly, I am thankful to the patients who each day grant us the opportunity to learn—and remind us of our humanity.

The single-most important teaching I’ve taken from residency is not a lengthy list of diseases and clinical manifestations, but rather a mindset: one that emphasizes curiosity, teamwork, compassion, and doing better than the status quo. Medicine is art as much as science, and each patient is an individual who will challenge us to provide care that is just right for them. As Weiss puts it, “Routines … represent in reality but the theoretical considerations, from which we must frequently deviate when faced by the problems of a particular patient.”

The coming years will mark a new phase as we move into different roles. Yet in many ways we will still be “in training.” For some, this will be formal, as fellows learning oncology, cardiology, and gastroenterology; others will serve as new primary care doctors learning to practice medicine more independently; and some will become hospitalists, leading teams of residents on the wards for the first time. Remembering Mrs. S’s question about whether I was a doctor in training, I can’t help but smile. Even though residency is over, the answer is yes; I can’t imagine any other kind.

Link to original article

Link to print version (published on July 8, 2013)