September 25, 2010 Leave a comment
I like the word floundering. It describes my state of existence as a second year resident. I am sandwiched between the most novice of physicians – interns – and the most senior residents, who will be full-fledged attendings in a matter of months. A four-year residency program is not unlike high school. In that scheme, I am the sophomore. Legend has it that the word sophomore is derived from the Greek, sophos (wise) and moros (foolish), or wise fool. It represents a time in training when you have gained just enough knowledge for it to become dangerous. It is the period of learning where there is a tendency to become overconfident – in medicine, this means that you are able to recognize most things, but you are not always cognizant of why you might be wrong or what you could be missing.
And so this is the proverbial sophomore year. And I am in the proverbial sophomore slump. In the UK, this is more commonly referred to as the “second year blues.” I am in a holding pattern, observing as time passes – in slow motion – around me. Waiting for enough time to pass so that I will have persevered through the most difficult part. Patients and stories are blending together. My enthusiasm for the hospital is dwindling, as every ounce of energy is drained from my reserves. Life in the hospital has become tiring.
But through it all, I know – intuitively – that I am learning. And my knowledge is increasing exponentially, although I am too exhausted to take notice. I walk into the emergency department with a new calm about me. I am not sure if it is sleep deprivation, or that dangerous over-confidence, or sheer emotional exhaustion. But the calm persists throughout the day, no matter what comes in that door – blood, screams, cries, swelling airways, exposed bone. Nothing surprises me anymore. I never realized that this is emergency medicine in its truest sense – a lack of adrenaline, a variety of tools and knowledge with which to analyze any and every problem quickly and efficiently. Triage remains the most important principle of this type of medicine.
I always keep my respect for the airway, and for the subtle details about patients’ lives that will change a diagnosis, but aside from those things, much of the rest of medicine is – finally – beginning to make sense. And much of it is at my fingertips. Yesterday, I was able to distinguish – from my history and physical exam – a kidney stone from appendicitis in a young man with right-sided abdominal pain. I would never have been able to do this just a year ago. I did it with ease, confidence, and humility – and still considered both diagnoses and ordered the appropriate tests.
The common piece of advice when you encounter a stressful situation as a physician – a code, a catastrophe, a surprise – is “first, check your own pulse.” My pulse has become constant. I am at peace in the emergency department. When things get crazy, I ride the wave and take care of the important things first. For the rest, I have learned to let go – to place things in the back of my mind, tucked away for a later time. This is how you manage medicine in a crisis. Prioritize, triage, and use your “medical instinct,” if you will – those years of knowledge which amount to a gut feeling – to do what is best. It is not out of the realm of possibility to succeed at this job. But this is the viewpoint of the sophomore. A couple of years from now, I will be writing that it is not out of the realm of possibility to fail at this job. But for now, I will embrace the sophomore slump and take from it the small amount of satisfaction – small successes, growing knowledge, and my sharpening clinical skills – that is has to offer. Floundering all along the way, flopping in the sand, an elephant seal navigating nowhere in particular – only waiting for the setting of the sun, the passage of time, and the imminent release of stress as I plop head first into the cool, salted waters of third year residency.