Monday, May 30, 2011

sink or swim

Hope you're having a good Memorial Day weekend, everyone.  As we enjoy our holiday, of course let's not forget our brave men and women in the armed forces, without whom this beautiful summer weekend with our families and loved ones would not be possible.

In the States, Memorial Day marks the official start of the summer season, and this makes me realize that the idea of summer, to someone in or recently departed from academic medicine, is very different from the idea of summer held by the rest of the population.  For most, summer means school's out.  Summer means vacation.  Summer means sunshine and barbecues and leisure.  But for the eight years that I was in academic medicine (I'm leaving out the year that I was a first-year med student, since first-years usually get their summers off, though they usually spend the time doing something unbearably earnest), summer meant one thing: new beginnings.

The Gregorian calendar begins in January, and most schools from elementary to university begin somewhere in the neighborhood of August/September.  But in medicine, the new year always begins towards the beginning of the summer.  One chapter ends, another chapter begins.

During the summer, usually on or close to July 1st, everyone in academic medicine moves up a peg.  Third year med students become Sub-Is.  Interns become residents.  Residents become new attendings.  New people come in to fill the spots vacated.  Everyone is in new roles, figuring out what they're supposed to be doing.  Want to know why the conventional wisdom is that you should never be admitted to a teaching hospital in July?  That's why.

Here's an excerpt from my book that I was thinking about today, and after the excerpt I'll tell you why.

A sub-internship, or “Sub-I” (as it is known to those of us who cannot get through a sentence without acronym or abbreviation) is basically the training bra of residency. It is a pre-requisite for graduation from medical school, consisting of a month where we assume the patient load and care responsibilities of a first-year resident (or “intern”), albeit with the increased supervision and support required by logic and law. It is a dress rehearsal for the real thing.

In one sense, being a Sub-I the logical progression from being a third year medical student. See one, do one, teach one is one oft repeated credo of academic medicine, and after a year of watching residents in action, it seems due time for us to start “doing” on our own. Sounds reasonable enough. However, the reality of the transition from third-year med student to Sub-I is more like being lifted dripping from a knee-deep wading pool in which beach balls and foam noodles lazily float, and thrown headfirst into the churning ocean, your only instructions being to keep your head above water and not die.

So.  Cal learned how to swim today.

He's going to be six in about two months, so he's definitely not, shall we say, precocious in his mastery of water survival tactics.  He had all the requisite skills to swim, but mostly he's just been kind of nervous around the water.  Didn't like to put his head in.  Didn't like to be in the pool without a flotation device.  Worried about getting water up his nose.  Worried about sinking.  I don't think he quite trusted, despite a number of increasingly scientific demonstrations about human tissue and buoyancy, that he would float.  Being a bit of a late swimmer myself, I remember that feeling well.  But I also knew from my own experience that all it would take was one moment--one leap of faith, or more accurately a second of forgetting his own doubt--for him to realize that yes, he was going to be OK in the water after all.

It's med school graduation season now, of course, and I hope it doesn't sound disingenuous (because it is quite simply the truth) that I often think about the crop of newly minted practitioners joining us in the real world.  And look, I don't have any good advice, I'm new enough at the game that I'm still trying to figure things out for myself.  But there's going to be a moment for all of you when you look up and realize that you're doing something that you didn't think you knew how to do.  That something you practiced and practiced and practiced somehow, likely while you weren't paying attention, became automatic.  That in the recesses of your brain, you actually knew something, remembered something, that will help an actual patient in your care.  It's that moment--the leap of faith, the forgetting of your doubt--that's going to make you realize something that you're only being told now and may not quite yet believe.

You're a doctor.

Welcome to the team.


  1. This made me tear up a little bit. 5 years post-med school graduation, I'm still a little bit astounded when someone says "doctor" and means me...

  2. Anonymous4:00 PM

    Oh my God. This post struck a chord in me. I'm rising to become a 3rd year Peds resident come July the 1st. And I've just completed my first floor month as an upper level resident. And I'm amazed at how I survived, and even thrived. I supervised the most acute floor in my hospital, where the post-cardiac surgery and oncology patients are, and by some bizarre happenstance, things went smoothly. Had a couple of rapid responses [which are near-codes at my hospital] and I managed to maintain my own pulse rate during those events. [The patients did fine, btw.]
    Yep, somehow along the way these past 2 years, while I was continuously mumbling under my breath about how little I know, I guess I was learning. And I'm relishing this new position of responsibility!


  3. Sandy4:04 PM

    Interesting; do some schools have you do "sub-I"s all of fourth year? Here, it's called "acting internship" (or AI, of course), and you generally just do one or maybe two months worth, in the field(s) you're most interested in, and you can start them as soon as you've finished the "core" rotations, which don't quite take up all of 3rd year. The rest of fourth year is just regular non-core rotations and away rotations. Most people do their AI(s) toward the end of third year, so they're behind them when they're writing up their residency apps.

  4. Cute video!

    Just finished reading your book after it arrived via Book Depository - I loved it!

    Quick question though - what happened to the pictures + comics? Cut out by the publisher??

  5. Yay Cal!

    For the record, I LOVED my sub-I. LOVED. Unlike any rotation I'd ever been on before. Even though it was terrifying at times, it was nice having actual responsibility, and to occasionally be listened to.

    I keep trying to remind myself of this whenever the terror that I will eventually have to finish my PhD strikes.

    Also, again -- YAY CAL!!!!

  6. Just graduated last weekend -- friends and family have been calling me "Dr." but I feel like I know NOTHING. Pretty scared!

  7. Sandy: Usually people just do one or two Sub-Is, which last a month each. Maybe some people do more, but those people are crazy gunners--most of the rest of the year consists of electives, which by schedule design tend to grow increasingly less demanding the closer you get to graduation.

    Polly: Comics were cut after the first round of edits because it was felt that they broke up the narrative flow. I tend to agree, but once I knew they were terminally cut from the manuscript, I put them all up online, so no huge loss there.

    Old MD Girl: Agree. My Sub-I was the first moment in all of med school when I really thought that I might be able to hack this job. And yes, Cal is VERY proud!

    Dr. Army Wife: You know much more than you feel like you do. You just need the opportunity to prove it to yourself. Congratulations, Doctor! :)

  8. Anonymous1:34 AM

    up north in Canada where I attended medical school, our baptism of fire is in our 3rd year where you're doing your core rotations for the first time but acting as sub-interns (carrying 1-3 patients each). Also, having to take all the clinical exams then. If you passed 3rd year, you're pretty much guaranteed to pass med school...fourth year is mostly electives.

  9. Anonymous3:26 PM

    Congrats to Cal! You know, now might not be a bad time to get Mack started swimming either. I've taught swimming in the past at a Y and quite a few families start their kid a little after they turn 2! Really! It's not too young and it might be a lot of fun for your boys to do things together.

  10. Courtney12:24 AM

    Thank you so much for this post! I just recently graduated from med school, moved to a brand new city and start orientation as a pediatric resident next week. I really needed that bit of encouragement. Love your blog by the way and can't wait to read your book!

  11. I've just followed your twitter link and noticed that you're #36 of medical memoirs on Amazon, but did you know that's a fake amount. By my count at least 14 of the places higher are the same book listed multiple times. (The curious life of Henrietta Lacks is there 4 or more).

    So you're nearly top 20! Woo hoo!

    Also Gah - no kindle edition outside the US yet.
    I'm waiting...