Doctors say the darnedest things

When I was a student, we were encouraged to have a 'thick skin' because attendings, residents, interns, nurses, social workers, MA's, PT's, and custodians all tended to lash out verbally at medical students. And it didn't really matter how good you were, or nice, or helpful. Eventually, someone would chew you out for no reason other than you are a convenient person to yell at. People have more scruples about kicking a cat.

I remember the times this happened to me. I was publicly humiliated by one attending at a conference for asking the drug rep a question. One surgeon threatened to make me do M&M, since this patient's imminent death was all my fault. One day I was assigned to eight patients in the morning, and I couldn't see them all before rounds, and the resident told me that I was lazy and useless, and should seriously consider dropping out of medical school. I strongly recall one attending who spent 20 minutes on rounds screaming at one intern until she broke down crying.

So when I graduated medical school, I promised myself that I would not perpetuate this horrible rite of passage. I would be nice. And that's such a noble thing to say to oneself, but in reality, I was just as bad. As a resident, I made no less than two interns cry, and there are a few students who likely went home and blogged about what a jerk I was after getting dressed down by me.

The problem for me is that I expect a lot out of people. I expect 100% all the time. That is the effort that I gave as a student and resident. That is the level I want. But my 100% is not the same as other people's. And it's not like I had to miss my daughter's soccer game or my wife's birthday.

When I finished residency, I promised myself that I would try to be more understanding. Being nice is tough. When you're pissed off, it's hard to turn that into nice. But as long as you're willing to listen and try to understand, even the most withering criticisms can at least be constructive.

Countdown to July 1: Attending

The last July 1st with any significance is after the last year of residency. At that point, a resident (AKA house officer, physician in training, indentured servant, scut monkey, etc.) completes his training and is board eligible. If you ever wondered what BCBE stands for, it's 'board certified / board eligible.'

Uniformly, residents discover that they have a limit to the amount of residency they can take. After a certain point in time, residency becomes intolerable. It is a continual nightmare having your judgment questioned continuously, and having your clinical decision making process derailed by someone who potentially knows less than you. In fact, most residents in their final year may know as much if not more factual medical knowledge than their superiors.

But practicing on your own is a different beast. There's no one questioning what you're doing, but there's also no one to offer advice or reassurance. There's no superior to appeal to.

It is an intensely isolating experience, and all those years of medical school and residency suddenly feel very empty. I thought that I was ready to be an attending when I was done with residency, but what I discovered was that there is no preparation for being your own doctor. At some point, you have to trust that you are right, and that can be hard to come by.

Advice to the new attending:
-Sometimes making any decision is more important than being right.
-Never let them see you sweat.
-Do not pull the 'Who's the doctor? You or me?' card unless you really mean it.
-Most importantly, trust no one.

Attending physician

I haven't written much about being an attending. Partly that is because I don't want to reveal who I am, but also, I feel like being an attending is a hard thing to get a good grip on. In some ways, it feels fantastic to be done with training, but it seems like it's actually quite a bit more stress.

As a resident, I had interns below me and attendings above me. There were tons of people whose job it was to question every decision I made. There were other residents around who could provide some input. As an attending, it's just me. There's no one else. It feels quite odd not having to run my decisions past someone else. After my first clinic, I grabbed one of my colleagues and talked about my patients. "Why are you telling me this?" he asked. It just felt so alien to make a decision and not have it questioned.

I feel like an acrobat without a safety net. I know what I'm doing. Heck, I'm board certified. But being an attending is an isolating experience. I miss having someone tell me that I'm doing the right thing. Now, I have to question my own decision making. I sit at home at night asking myself, "Did I really need that stress test?" Worse yet, I've already had a couple mortalities, and I can't blame anyone but myself.

But for those of you slogging through residency, let me tell you that on balance I am very glad to be an attending. All this time, all the work, and now I am the one calling the shots. That has a price, and sometimes I don't call 'em right, but now they are my mistakes to make, and that is both scary and wonderful.