I sit at the front of a lecture hall, facing 50 newly minted doctors. In a few days they will enter the hospital for the first time as M.D.s. I was in their shoes two years ago. Now, as a senior resident entering the last year of my training, I’ve been asked to offer them some advice about the year ahead as interns.
As a new doctor, you will make a save. Over the course of the year, as your knowledge, confidence, and neuroticism grow, you will inevitably catch something that no one else did. Maybe it’s a key diagnosis: “How many bowel movements have you had in the last day?” I ask my patient. “Forty? And urinary incontinence, too?” I order an MRI, which reveals what I feared — a mass pressing on my patient’s spinal cord.
Maybe you’ll find that your most satisfying “saves” aren’t emergencies but helping someone take gradual, positive steps in the right direction. My patient grins and pats his arm. “Doc, I love this nicotine patch!” After 40 years of smoking, he finally quits for good. Those might not be the stories you’ll swap with your colleagues. But they can often do the most good for your patients.
As a new doctor, you will learn that your big save may be someone else’s worst moment. I am making morning rounds when I notice something very wrong. My patient with metastatic colon cancer is moaning in pain, her heart racing. I accompany her to a CT scan that shows her bowel has ripped open, spilling its contents into her abdominal cavity. I reach the surgeon on call, who takes one look and renders his decision: “This is metastatic cancer — no surgery. Call palliative care instead.” I push back. “But she has a good one to two years ahead of her,” I argue.
Five phone calls, two trips to radiology, and three hours later, I convince the surgical team. The operation goes well and, as I walk home after visiting the patient in her post-op room, I think, “This is it. Today, I was more than a cog; more than a cookie cutter; a real value add.”
One month later, the patient and her family show their gratitude with a formal grievance against the medical team. “The doctors kept changing their mind. Surgery, no surgery, surgery, no surgery. It was chaos!” they wrote. I think back: Hadn’t I explained our ongoing thought process? Suddenly, you will re-read your story in a new light. This was your value add; it was also the time you failed to communicate with your patient.
As a new doctor, you will meet a patient who hates you. Maybe your patient is sexist or racist; maybe he disrespects you; maybe you share completely different worldviews. You will also have to deal with the feeling of disliking someone you are supposed to be caring for. It’s a rotten feeling you must learn to manage.
My patient lied. Not once, not twice, but over and over again as she took higher and higher amounts of narcotics each day and then became irate when I didn’t refill the prescriptions for them. Despite knowing, rationally, that anger always has a source — from pain, from fear, from feeling alone — I began to dread seeing her, and then scolded myself for my own unprofessionalism. “We are tapering your narcotics,” I finally say. “If you don’t agree, I can help you find a new doctor.” She found a new doctor. She never thanked me. I never said I’m sorry.
As a new doctor, you will give bad news. “Five years cancer free!” my patient says cheerfully, knocking on the wooden nightstand beside him. “The only thing is, I just went on vacation and felt tired, really tired. My muscles ached and I couldn’t swim, which is what I went on vacation to do,” he adds. I gasp as I watch his PET scan light up with cancer — all his aches and pains now dreadfully explained. Cancer is the muscle he thought he pulled in his back last month. Cancer is why he was feeling more short of breath. Cancer is the reason his hip hasn’t been bending quite the way it used to. “I’m sorry,” I say. “I have bad news. Your cancer is back. And it has spread.”
As a new doctor, you will recommend stopping treatment. This will be one of the hardest choices you will make. That’s good. It’s supposed to be hard. This is someone’s life. What could be more serious than that? Leave no stone unturned before making this call. “Your father has been on life support for a month,” I say to my patient’s family, “and his lungs have only gotten worse. Now other organs are shutting down and he isn’t responding to us. The machines can keep him going, but I fear he won’t be able to survive without them.” I pull up his latest CT scan and show them the tiny patches of good lung in a sea of hardened, non-functional tissue.
His daughter cries and says, “he never wanted to live like this.” I take a deep breath and recommend that we think about removing the machines and making him comfortable. I recommend we think about how best to honor his wishes. I recommend we allow him a peaceful death.
As a new doctor, you will not solve every problem. My 28-year-old patient doesn’t look older than a teenager. For the past year, her body has been wasting away, shriveling under the wrath of an illness no one has been able to identify. When I meet her, she weighs 70 pounds. She wears a diaper; the diarrhea won’t stop. Her labs paint a portrait of someone who loses all of her nutrition.
I pore through her medical records. It takes days, as there are hundreds of sheets from many specialists and numerous hospitals. Yet I am optimistic: Time is often a doctor’s limiting reagent, so if I just take the time, I can solve this. One month later, I am losing hope as she drops to 60 pounds. One year later, I pray that her autopsy can help others.
As a new doctor, you will make the wrong prognosis. I’m on call in the intensive care unit. All day I have been going back and forth with the attending physician about a 92-year-old woman with heart failure. Her breathing is slowing, the level of carbon dioxide in her blood is rising, and she’s falling into a deep sleep. She doesn’t want any artificial ventilation, and I’m running out of options. Shortly after 10 p.m., the attending tells me that I did my best, and I realize: This is what dying looks like.
I gather my patient’s sons. “I’m worried that your mother won’t survive the night. If there’s anyone she would want to see, I recommend you call them now.” Grandchildren, neighbors, nieces, nephews, and friends trickle in at midnight. They form a tight circle around her bedside, whispering loving words until the sun comes up. The following morning, she is slathering jam on a slice of toast. “How are you?” I ask dumbly. “I’m fine, dear,” she replies. “And you?” Our conversations are similar every morning until the day she goes home.
How could we have been so wrong, so bad at prognosticating? But if you are going to be wrong, better to call family too early than too late. None of her visitors regretted staying the night.
As a new doctor, you will feel powerless. You will find yourself battling big, systemic barriers beyond your control, and you will wonder if anything you are doing makes a difference. You will prescribe expensive medications to people you know can’t afford them. You will advise healthy eating to a patient who lives in a food desert. You will go up against insurance companies, fighting to cover your patient’s medical necessary care, and you will lose. You will feel like you are sticking Band-Aids on chronic illnesses. You will ask yourself, more than once, “What is the point?”
But you will push and push and keep pushing because once in a while something will budge. Once in a while you will push so hard even you are surprised when a barrier falls down. And if enough of you push, even slowly, maybe you can change things.
As a new doctor, take your first steps in that role with humility. May they be better, deeper, and more meaningful than you ever could have imagined.
Ilana Yurkiewicz, M.D., is a senior resident in internal medicine at Stanford University.