Long ago and far away, on my first day of internship in a Boston hospital, I was handed four pagers to wear. Almost as soon as I clipped them to the waist of my scrubs, the leftmost one chirped. According to my senior resident, this meant that the emergency department had a consult for me.
A consult for me—the just-finished-medical-school student who hadn’t done any work in OB/GYN since my subinternship 10 months earlier? For me—the fledgling doctor who couldn’t quite always reliably find the cervix on examination? For me—someone so new to this hospital that I wasn’t sure where the emergency department was located?
My senior resident saw the look of incipient panic on my face. She patted me on the shoulder and said ”Look. You will go see the patient. You will go take the history. You will collect the vital signs and feel her belly. If you’re not comfortable, don’t do the pelvic exam. Then you’ll call me. Because—and you already know this—you’re incompetent. You’re supposed to be incompetent, for a while yet. So right now, I have two rules for you: (1) Be on time. (2) Tell the truth. Do those two things. Anything else you can do for the next two weeks is gravy.”
I remember those two rules every year in July and August, when I get my new medical students at Albert Einstein College of Medicine and my new interns at Montefiore.
Expectations: High and Low
Physicians, as teachers and clinicians, have respectably high expectations for our medical trainees. They are, to a person, talented, intelligent and devoted people—that’s how they’ve gotten this far. But also, we have respectably low expectations—we realize that they’re new to what we do, and they’re in training precisely because they’re not competent (yet), and precisely because they need to become competent (very soon).
The rules I was given—be on time, tell the truth—sound deceptively easy. But like most simple rules, they are really tough to follow. Because it turns out, these two rules are some of the foundations of professionalism for any vocation. This professionalism is particularly important in the early stages of a young doctor’s career, because many of our trainees have gone straight through from high school to med school without ever having held down a full-time job.
These rules mean that what I want to see from students or residents on day 1 is not medical content, or facility with procedures, or any of the things they have been cramming. What I want to see is professionals, aware of their limitations, ready to start work.
More Rules for Med Students and Residents
The two rules given to me by my senior resident, way back then, were a good start. But in the years since, I’ve added to them, because I think we can ask for more (even on day 1). Here is my updated list of expectations for new trainees for days 1 through 14:
(1) Be on time. This is hard when “on time” is 6 a.m., or earlier. We know.
(2) Tell the truth. Especially if that truth is “I don’t know” or “I forgot to check”; both are hard to say, but in patient care, an untruth can be dangerous.
(3) Keep showing up. Show up in body but also show up in spirit, and keep showing up, even (especially) when it’s hard to be there every day…or if you think you never, ever want to practice this kind of medicine again.
(4) Go see the patients. Do the physical exam, as much as you are capable of doing safely and well. But also be with the patients: talk with them, observe them, tell me as much as you can about what is really going on. Looking up their lab results on the computer will never get you as far as actual, close physical contact. This is the closest we can get to the “truth” that we need for care; remember rule 2?
(5) Be kind. Be kind to your staff, to your seniors, to yourself. Sit when you can, eat when you can. And make sure to bring some snacks in your white-coat pockets, while you’re at it.
Do all of these things on day 1, and you’ll learn a lot, and probably have a good first two weeks. That will be just in time for the expectations to increase again—but you’ll be ready.
