Fourth Year I

We only had a brief breath of time to reflect on this transition between third and fourth year. Like that immensely scary change from second year in the lecture hall to third year on the wards, this transition represents an acceptance of greater responsibility. We're supposed to know something now; that guileless smile no longer works. We're taking a more central role in caring for patients, making clinical decisions, refining our judgment. It's terrifying. I'll be honest. I don't feel like I know much at all. I can tango if I'm asked the right questions, but as a fourth year, we have to generate our own questions. There are no more prompts, no more fill in the blanks, only a sick person and whatever shots you decide to call.

At the end of third year, I feel good. I survived. It's supposed to be the "hardest" year, and I enjoyed it. It was great going into a rotation knowing absolutely nothing yet coming out knowing something. The people I worked with loved to teach and try to get us to go into the specialty. I saw open heart surgery, I delivered babies, I had one woman ask me to be her primary care doctor. I saw what it was like to be incarcerated or paralyzed or schizophrenic or a parent. Moments like that make all the interim worth it. It was not easy, and I would be wrong to pretend it was. There were distinct hours, days, weeks when I wished I was doing something else. I floundered. I had no confidence in myself. I thought about running away and writing the next great American novel or joining a band.

I've changed. The transformation is quite remarkable yet I don't notice it until I reflect. For one, naked people don't bother me (the confounder, of course, is living in San Francisco; Bay to Breakers is this weekend). Seriously though, I have more confidence than when I started; I wear my white coat rather than let it wear me. I feel more a doctor than an imposter, and while that is an expected change, I struggle to prevent myself from adopting bad habits. I try to preserve humility, empathize with patients, and ignore the clock. After a year on the wards, I've learned to think on my feet. I remember the beginning of third year when my routine was to see a patient, rifle through my handbooks trying to figure out what the patient has, google, wikipedia, or UpToDate the disease to figure out what tests and treatments I would need, and finally present to a preceptor. My rate was two to three patients an afternoon clinic. Now, I find myself more comfortable juggling multiple patients simultaneously, thinking on the fly of what I want, and relying more on my "fund of knowledge" rather than external sources. I can hear presentations of other patients and feel the cogwheels in my head turning, trying to figure out what is going on.