Learning on the Job

UCSF trained me well. I find that I actually know most of the medical facts I need on a day-to-day basis. Although of course I'm constantly reviewing and relearning things, I was surprised to realize internship is less about rounding out my fund of knowledge and more about learning to apply it. The application, though, is a whole different story. As medical students, we learn to anticipate pimping, getting asked questions by an attending. We learn to review Calot's triangle before scrubbing into a cholecystectomy; that if we're placing an arterial line, we'll get asked about the Allen test; or if a patient has an EKG, we'll be asked to read it. And we get pretty good at answering these questions.

But now as a resident, I don't have the luxury of having my questions be hypothetical. When I am forced to think about fever, it's not to answer a question from an attending, it's because my patient's temperature is high. When a nurse calls to tell me my patient's blood pressure is 200/40, I need to figure out why. That transition from simply answering a question on rounds to committing to a clinical judgment for a patient is everything about being a resident.

I've been faced with half a dozen clinical situations where there's a vast chasm between knowing the right answer and committing to it. On my second night on call in the ICU, a patient developed acute atrial fibrillation, a problem whose UpToDate article I've read half a dozen times. But the difference between answering amiodarone to an attending's question and writing out that bolus and drip is remarkable. I second guess myself all the time. Is this right? How sure am I? The stakes are so much higher; as a medical student, we risk our grades when we take a stab at an answer; as a resident, we're responsible for someone's well-being.

My third night on call, I had to manage a vasopressor in a patient who was hypotensive. He was dialysis-dependent with end stage renal disease, and that meant I had to balance giving fluids with titrating my drugs. I spent most of the night at the bedside, evaluating, re-evaluating, adjusting up, adjusting down, and it taught me that there is no substitute for experience. I had read the textbook chapter on vasopressors, but I never fully understood them until I spent an entire night awake keeping this patient alive. The growth curve and transition from student to resident is actually quite remarkable, and I've been thinking about it a lot lately.