Posted by: notdeaddinosaur | June 28, 2011

Imposter Pep Talk

Today I would like to address myself to my young (some not so young) friends and students on the threshold of postgraduate medical education.

Yesterday you wore sweltering gowns and funny hats while someone stood behind you and, instead of garrotting you to death, slipped a medieval accoutrement to the gown around your neck. (Some say that by this time next year, you’ll have realized it was indeed a garrote.) By today, you’ve accomplished whatever relocating may have been required and are hip deep in assorted orientations. You’ll have had a new ID badge created, toured the rest of the hospital (this time including the obscure but required areas containing the cafeteria, bathrooms on every floor, and on call quarters), trained on the proprietary CPOE that looks nothing like the one you learned in med school, and now have nothing to do but wait nervously for the witching hour of July 1st.

Your family and friends probably think you are feeling excited and eager to begin this new phase of your life. After all, you’ve worked for it so long and so hard; now it’s here! You’re a doctor, and now, finally, you are about to begin your calling. Sure, they understand you’re probably a little nervous too. Who wouldn’t be? It’s a big step. But you’ve spent all that time studying, you’ve passed your boards; by now, you know what you’re doing.

Right.

What’s really going on in your head, of course, is something more like this:

Holy shit! They’re about to send me out onto the floors to take care of real live patients all by myself, and I have no idea what the hell I’m doing! And the worst thing about it is that I have everyone fooled; the professors, the attendings, the senior residents, everyone who ever gave me a positive evaluation; all of them! I’ve got every last one of them fooled into thinking I have a fucking clue! People are calling me “Doctor” and I turn to see who’s behind me. I am the biggest imposter EVER! I am totally going to kill someone before this is over. <begin panic attack>

How do I know this is what you’re thinking? Because it’s exactly what I was thinking right about then. Not only that, but as residency progressed and late night discussions with peers flowed in earnest (along with mass quantities of beer and other intoxicants), it turns out that every single one of us was thinking the exact same thing, and, I’m pretty sure, has from time immemorial.

Senior residents? The ones who always had the answers? Clueless, inside their own heads.

Attendings? The ones who had even more answers than the seniors? The day they went out on their own, I guarantee they were thinking, at the very least, “An Attending? Me? I feel like such an imposter.”

It turns out there’s a name for this: the imposter phenomenon. Even though everyone may not admit it, I can promise you that just about every single newly graduated MD starting residency training experiences this fear.

When does it go away?

After more than twenty years in practice…I’ll let you know.

Okay, that’s not quite true. Confidence builds gradually over the years so that by now, more often than not, I really do feel like I know what I’m doing. But that doesn’t keep me from stopping right before seeing a new patient and wondering for a moment, “What if I have no idea what’s wrong with this person?”

So where’s the advice? Here you go:

Chill.

First: you know more than you think you do. Just go back in your mind to the beginning of your clerkships. That’s when you were totally clueless. Well, sure, you say; I know more than a third year. But there’s so much more I don’t know.

Here’s the point: knowledge comes from experience, which is cumulative. I promise you’ll be soaking up everything you need to know like a terrified little sponge. With each passing rotation, you’ll find that cold, tight knot in your belly just a tiny bit looser. It’ll clench back up again whenever you get called to a code, or have to do anything you haven’t done before. But the second time will be a little easier (well, a little less terrifying, at any rate). And so on. Take home message: it’s a gradual process.

Second: don’t get so bent out of shape about all the touchy-feely stuff right now. Yes, it’s important to listen to patients, to be emotionally available to their families, to get a complete social history, to remember that patients are people and not just diseases; all that fuzzy family medicine stuff the surgeons like to rag on us for. But you have to get the basics down cold first.

Those lists of questions from the Review of systems? You need that memorized so you can pull the right questions up when you need them. You need to know that bloody diarrhea and abdominal pain should make you think about inflammatory bowel disease, but you also have to learn that you have to ask that patient about joint pain and skin rashes. You need to be able to interpret ABGs and EKGs at a glance. You have to be able to admit a patient with “chest pain, r/o MI” in your sleep — and you often will.

It’s like listening to Ryan Howard talk about hitting; getting in the zone, seeing the ball, pointing the bat out to center field like Babe Ruth; that sort of thing. All that abstract fluff is well and good for the big leagues, but you have to drill your ass off first. Only when the basics have become second nature does the rest of that stuff even make sense. Surgical judgment is well and good, but you still need to be able to tie one-handed knots in your sleep.

Bottom line: you will survive. In fact, you will thrive. This is, after all, what you’ve worked for all these years. Be patient with yourself. Work hard, of course; no need to say that, as you could never have gotten this far otherwise. But you will make it. And you will be awesome.

</panic attack>

 

I’m talking to you, CW.

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Responses

  1. Not only new docs but other professionals go through this. When this crotchty old guy in his 80s, whom Dr.Dino has known for years, established his own law practice, he was amazed when clients followed his advice. Iin later years he took if for granted that they would, and still later he was amazed when, on rare occasions and to their detriment, they did not. So it goes, with passing time professionals do become more knowledgeable and more confident about knowing what they know. This COG had a funy experience some time back when a pompous opposing counsel told him, “I know I’m right because I’ve been practicing law for 30 years.” The COG’s reply was “That’s impressive, I once had 30 years experience.” to which the POC replied, “What do you mean, you once had 30 years experience?” The COG replied, “Yes, I had 30 years experience 25 years ago.” What a polite way of saying FU.

  2. […] To those of you who just got out of medical school: Sage words of a Dinosaur. […]

  3. Good advice and as COG notes, it’s not just physicians. The day I finished my paramedic internship and got the new badge that said “Paramedic” on it instead of EMT, I was sure someone had made a terrible mistake. It took about another year before I was comfortable and could work up an acute CHF patient without becoming more diaphoretic than they were.

    With time comes experience and with experience comes confidence.

  4. Great post as always. I have been doing the solo FP thing for 15 years. I know more now than I did starting a solo practice and feel a lot more confident. That said, the insurance companies do not care that I know more than a first year new doctor and pay me less per office visit than the large groups that hire the new docs. Confidence and intelligence is not always respected or rewarded.


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