My Life as a Medical Trainee

As I was walking up a hill, the hospital came into my sight: a mid-size hospital with blue color painted through the middle and a small entrance, and this is the teaching hospital in Worcester, Massachusetts, where I was going to spend three years of my medical training. It was the first week of July in 1998, and the sight of that teaching hospital stirred several emotions in me. I was happy, yet anxious; I was confident of my medical knowledge, yet there was a grain of self-doubt; and above all, I felt relieved that as a foreign medical graduate I was able to secure a spot for training in internal medicine at this beautiful hospital in a beautiful New England town.

In many ways, starting my medical internship was a big transition. I was relatively a new immigrant in this country (about 2 years of residence) and I did not have much social support: my family was back home in Bangladesh where I grew up, and I was desperate for a paycheck and a clinical job. I had a solid medical education in a foreign country, and I had one year of training after graduation. If I had not matched (a process by which medical students and trainees are assigned to a teaching hospital), I thought of doing an advanced degree (MPH, for example) or getting involved in clinical research. Now that I was going to start this training program, I knew that I could not afford to fail. I was ready for hard work and long hours of commitment within the four walls of that hospital.

Fast forward a few days, and here I was at my first assignment as an intern: being part of a neurology consult team. I was glad that I started out with that rotation. I did not have to carry a patient load as I was not part of a primary medical team; I had more time to learn how things run in a busy American acute care hospital; and at least for a few weeks I did not have to stay for extended hours to take care of patients assigned to me. As an intern in the neurology team, my job was to evaluate a few patients per day and discuss the plan of care with my supervising physician (we call them an attending) and then communicate (both verbally and in writing) a set of recommendations for those patients. I still remember the very first patient that I saw – a patient admitted with “altered mental status” and my job was to assess the patient, figure out what was wrong and then discuss my thoughts with my neurology team. It took me quite a bit of time to find the paper chart; I had to ask the nurse if I could not find the chart by the patient door, where else should I look for? I also learned that lab tests were reported to and stored in a computer system. Yes, I remember being in training for accessing labs, but by then I had forgotten how to toggle between “dark screens” of information to review all labs and to get to the end of the report. Once I managed to get a fair assessment of the patient and I was ready to present the case, my neurology resident (a senior level trainee in neurology) hurried me to do a thorough oral presentation. I paused and asked her for guidance. I was nervous; I knew the elements of a good case presentation, but I did not know if there was a different expectation. After all, in my medical school, our version of case presentation was different. It was shorter and focused mostly on examination and overall assessment. I was also anxious about my accent; I was worried about my volume and rate of speech as a non-native speaker of English. I think I managed that rotation (1 month) without any “troubles”; I learned about patient flow, clinical care and documentation processes, and most importantly, where to find chart and how to keep track of information, however mundane that seems, about my patients.

Two months into my intern year, I had the real dose of hard work as I started my core medicine floor rotation. I spent many long hours from the early morning to evening, running between hospital floors, figuring out where my assigned patient is in the busy emergency room, keeping hordes of paperwork (mostly copy of history and physical examination notes) in my white coat pockets, doing rounds and case presentations, attending educational morning rounds and grand rounds, and promptly answering my pages (yes, we used bulky pagers!) from the floor nurses and team members. I learned some survival tips from my senior residents and attendings: eat lunch whenever you have time, if you want the floor nurses to help you with your patients, answer their calls and pages promptly, talk to your family and significant others ( I had none in the U.S. then) while at lunch, and offer help to your fellow interns and residents during night float (rotating patient care responsibilities during night). Each day was packed with activities; I was getting tired, having less sleep, but the learning was steep, albeit many stumbles, and occasional “tough” advice (about my shortcomings and inefficiencies) from my senior, supervising residents. It was truly a bootcamp!

I vividly remember an evening during my intern year when I felt so hopeless and doubted myself about surviving this training. Well, I had my first experience to do a dictation of a discharge summary for a patient who had spent several weeks in our medicine unit and had complex set of issues and procedures. I sat by a large pile of paper charts and did not know where to begin! I started writing key events in a piece of paper with details, listed all procedures and consultations, thinking that I would just dictate off that piece of paper. It was not working; I figured I was doing redundant work and that I was putting in too many details and getting frustrated about the dictation process. I dreaded I would spend the whole evening and still could not get anything done. A fellow intern who went to medical school in the U.S. came to my rescue, but he first asked if I have ever done a dictation as a medical student. My answer was no. “Well, there is a first time for everything, and let me show you how I review chart and start the dictation of a discharge summary”, he said something to this extent. I felt so relieved with his help. He gave me a lot of good tips, showed me how and where to start, how to pause the telephonic dictation system and go back to key sections in the chart, and above all, told me only to list key diagnoses, related tests, and follow-up plans for that patient. I had many moments such as this during my training. I had moments of embarrassment for not knowing the right information at the right time; I was unorganized in my case presentation in the beginning; I was slow to figure out care processes, the learning environment, and even, some common American slangs that many of my patients used during clinical interactions. Every time I stumbled, I picked myself up; every time I had self-doubt, I had support and coaching from my peers and caring faculty; and by the end of my first year, I felt I was going to make it.

Medical training in the U.S. is quite unique and essential for having foundational knowledge and skills for being a competent doctor, and mine was not any different. I had to deal with so many transitions as I moved from one rotation to the next, during my second and third years when I had more authority and supervisory responsibilities. I learned a great deal about complex patient care, processes of care, detailed documentation about care, communication to other physicians and patients about diagnoses and care plan. By the time I was in my third year, I felt I was ready for managing most inpatient admissions with a fair amount of confidence. Reflecting on my three years of learning and training, a high-level summary of my growth can be summed up in the following manner: I was consciously incompetent (knowledge and skills needed constant supervision and guidance from books and seasoned trainees and staff attendings) as an intern, then consciously competent (skills and knowledge are mature and a sense of competence developed – some supervision needed) as a second year resident, and then unconsciously competent ( knowledge and skills are seemingly automatic, well developed to become a competent physician – almost no supervision needed) as a third year resident.

On a very high level, my medical training was a series of transitions. It was tough and it tested my resilience. Through all those moments of change and transitions, my mantra was not to quit and survive “one month at a time” (diverse patient care experiences, each lasting only a month) and keep pushing through the first year, and then the second year and onward. I also had great moments of happiness, fun, and a sense of belonging to my intern class and to the larger group of peers and superiors that I worked with. At the end, I was immensely proud of myself, and I was thankful of our teaching faculty who had to put up with me and other foreign graduates with thick English accent and different cultural norms about patient care.

So, my life as a trainee was quite a ride. Most physicians, like myself, have fond memories of their training. After all, this is something that builds a set of foundational pillars (knowledge, skills, attitudes, and behaviors) for us to be competent and compassionate in our professional career and perhaps in our personal lives.

Thanks for reading. At the next newsletter, I would share about my failed attempt to become a specialist. Until then, stay well.