The first time you lose a patient is a profound and unnerving experience.
For me, it was when I was night float during the third week of intern year. I showed up, got handed a stack of lists, and thereby lost the worst game of hot potato in my life. The nurse called me to the bedside of a sick patient like I was some sort of medical professional. I didn't know what to do so I called my senior who calmly and expertly helped stabilize the patient. Unfortunately, the patient's condition continued to deteriorate and before we could transport them to the ICU, they coded. When we pronounced them dead, I felt responsible and helpless. I was brand new, and the only thing I could do was call someone who actually knew what they were doing. I wasn't sure how I was going to get through 3 years of this.
Flash forward 3 years: I'm now one of the internal medicine chief residents and I just finished my first week as an attending on the chief service. I'm still figuring things out, but it's hard to explain just how transformative residency has been for me. Sure, I was nervous on my first day as an attending, but I knew I could handle it. I even ! Residency changed me for the better. Here are a few things I wish I understood when I started.
Sick Patients Usually Don't Do Well
This is not a profound statement, but it's a tough lesson to learn. We became doctors to help patients and to save lives. It's easy, therefore, to blame bad patient outcomes on bad patient care. You end up using the phrase "if only I had..." as an instrument of self-flagellation. Sometimes you don't provide perfect care, but generally, subtle differences in management don't produce different outcomes. In one of my favorite episodes of Scrubs, "My Lucky Day," J.D. is haunted by the thought that he missed something. Dr. Cox tells him that what he missed was luck. Sometimes, patients are unlucky, and the best care we have to offer is not going to change that. It is humbling and difficult to accept, but it is also incredibly important.
You Will Make Mistakes
Just because some mistakes don't change outcomes, it doesn't make it easier to accept them. We should, of course, strive to improve our practice and learn from mistakes. The only way to do this is to admit our mistakes, talk about them, and figure out what to do differently next time. You will find -- more often than not -- that others have made similar mistakes. And if they haven't, you're giving them an opportunity to learn from you before they do the same thing.
This Is Not Normal
When I talk to my friends outside of medicine about what I do, it often strikes me how strange my life is. None of my friends in accounting have ever had to tell someone their loved one is dying, and yet, that's a fairly common occurrence for me. It is truly a privilege to care for people at one of the most difficult times in their lives. But a trap I fell into during intern year was that I didn't appreciate how abnormal this was. Like the proverbial frog in the pot, we don't realize that the temperature is slowly rising throughout our training. We can't treat every loss like that of a family member and still do our job. But if pain and death seem normal, then there's no reason to support or care for those who are suffering. Not only does that callousness impact our patients and their caregivers, it also affects our sense of purpose and fulfillment, and cheapens the sacrifices we made to enter this profession. It takes time to find the right balance in responding to patient loss. Some days will hurt, and that just means you're doing it right.
You Are Now Part of a Team
Your test scores don't matter. Your individual knowledge about a topic doesn't matter much. What matters is that you work as part of a team, and that the team succeeds in taking care of patients. It is a paradigm shift from all of your other training that focused on individual evaluations. This is also the best part of residency. It means you can rely on your co-residents for help, and you can support them too. When you're down in the trenches, you're not alone. You get to make profound and durable friendships with the people you spend 80 hours a week with, which means going to work can actually be fun (in moderation).
It's Always Your Fault -- Especially When It Isn't
As the intern, you are usually the primary person taking care of each patient. Therefore, you are the lightning rod for all of their anger and frustration. I went to pre-round on my patients during intern year after having a day off, and every single one of them yelled at me. They weren't actually mad at me, but I was there, so I was the one they yelled at. It was hard not to take it personally, even though I knew none of it was my fault. In the afternoon, they almost all apologized. Patients are going to yell at you, but usually, it's just because you are the one they see and trust. And when gratefulness for that experience doesn't work, find a co-resident to confide in. That usually helped me.
Residency Is Actually Fun
I loved residency. It was difficult, but after spending so much time and effort to get there, I was finally able to function as a doctor for the first time. I made decisions that saved people's lives. I got to comfort patients and their families when things didn't go well. I learned a lot about myself -- my resiliency and my limits. I have stories to tell for years, and I made good friends to share them with. I really couldn't have asked for much more.
The feelings of guilt and responsibility over losing a patient haven't gone away, but I've learned how to manage them. Residency humbled me, and I now know that the most important thing to learn as a doctor is when to ask for help. I also know that a lot of patient care has little to do with what decisions I do or don't make, and that sometimes all I can be is there. There with the sick patient. There with the grieving family. There with the overwhelmed colleague. "To cure sometimes, to relieve often, and to comfort always," as the great William Osler, MD, said.
Residency is tough, and I know you may not feel ready. But you just have to trust yourself. You are a doctor, after all.
is chief resident of internal medicine at Temple University Hospital in Philadelphia.