In July 2022, I was invited as Keynote Speaker for the AMA Junior doctor series. The invitation was to talk about how to navigate the transition between medical school and working as clinicians
I was thoroughly briefed by Ruchee from the organising committee that the pandemic landscape of last two years had had substantial impact upon training. Moving from a face-to-face learning environment to a virtual learning platform meant less soft skill exposure, less in situ learning on wards or with peers, and less exposure to potential mentors, resulting in graduates feeling less confident about understanding what is expected of them.
Here is what I shared.
The intern year is arguably the most challenging year of your entire career. The learning curve is steep – it is unlikely to ever be this steep again. And in the early years, just when you think you’ve got the hang of it, you move into another rotation and being the ascent again.
It’s not just the technical aspect of the job – looking after patients – but it’s learning the system (how to order imaging), learning your team (what is the structure of the ward round, how does this boss like things done) – learning the CULTURE of health care.
It’s also about learning about YOU. What kind of a doctor are you going to be? You have more control over this than you may realise. You are going to see a LOT of clinicians practice their craft, technically and professionally.
And you will make choices, some deliberate and some subconscious with respect to what attributes you are going to develop, and – equally importantly – what attributes you may work intentionally to ensure you do NOT adopt!
I am now 25 years down the road from my internship, and while I have plenty of ideas I was lucky to be able to crowd-source some contemporary insights from interns, senior residents (Chiara), my ED medical education officer (Jess), other consultants (Chris, Audra) and the Director of Clinical Training (Shane) – thank you!
I have distilled these insights into 10 tips for transitioning from student to intern and beyond.
1. Don’t compare your insides with everyone else’s outsides
It’s normal to feel overwhelmed and to want to cry!
I promise you that almost everyone else feels the same, even if they LOOK confident on the outside. And that you probably look confident on the outside, even though you feel so wobbly on the inside.
Don’t fall into the trap of feeling lesser than everyone else. Chances are, you’re doing just fine – hang in.
2. What is expected of you? Do the basics well
The learning curve is incredibly steep because you go from no responsibility, where you’re assigned to rotations and lectures, but if you don’t show up, there probably won’t be a consequence to anyone else, and then move to a proper job where you have a full-on workload, responsibility and accountability.
It’s like going from the passenger seat into the driver’s seat. And sometimes it may feel like the car is on fire.
Focus on doing the basics well. Take a thoughtful history, do a thorough examination, come up with an impression. Be good at cannulas, venepuncture and IDCs. Know how to recognise a sick patient and to call for help early.
But also seek opportunities to extend yourself. Try to get into the driver’s seat, even though it may be uncomfortable: do a less common procedure under supervision, extend yourself to a differential diagnosis, an investigation list, a preliminary management plan. Write an entry note in the medical record or a discharge letter or summary and have it checked. Ask to accompany the senior doctor when they are going to talk to a patient or family, especially when it’s difficult news.
Most of what I’ve learned about gently and clearly breaking bad news, I have learned from asking my consultant if I could come along when they needed to tell family that a loved one was gravely ill.
3. Pay attention to those non-technical or soft skills (which really aren’t actually soft at all…)
Over many years of supervising and evaluating junior doctors and trainees, my consistent observation was that when they struggled, it was almost NEVER a deficit of knowledge or procedural skill, and almost always to do with perceived attitude or professionalism.
Speaking to our DCT last week, this theme is borne out currently. Junior doctors are reliably proficient at cognitive and psychomotor skills, but when they struggle, it’s typically in the affective domain.
Now, assessments of attitude and professionalism can be subjective. My tip here is to pay careful attention to intention and even more attention to your impact. Your approach may be based on sound intention and integrity, but somewhere between that starting point and the end-point (or perhaps a side effect) of your action, you may inadvertently come across as entitled, rigid or close-minded.
Refusing to commence work a minute before your start time, never staying back late and always taking your break at a set time amount to excellent self-care, but at a team or service level, are “me-centric”. Find a balance between looking after yourself while still serving the function of your team in delivering excellent patient care.
Seeing yourself as an integral part of the team can help with embracing a sense of accountability, and this will enhance your reputation as you progress through the early years.
There will be times, however, that you feel that what is expected of you is unjust, unsustainable, even untenable. Your roster may be overloaded causing you fatigue, you may feel harassed or bullied, you may feel disadvantaged when seeking opportunity. So…
4. Know how to advocate for yourself
It’s tough when you’re junior because you’re vulnerable. The person you may have a complaint against may be the same person who will be completing your term evaluation, perhaps even deciding whether you get onto a training program.
Newer generations are far more likely to speak up than mine has been. This is excellent but be aware that my generation is still getting used to this – and you don’t want to inadvertently come across as entitled.
Start with robust peer support. If you achieve nothing else, you will at least know that your experience is valid.
Seek support elsewhere also, like a mentor or the Medical Education Unit. Behave like the professional adult you are – communicate assertively but ALWAYS be respectful. Try to find and present a solution along with the problem.
5. Be an excellent communicator – be a superb listener
What people will want will vary from person to person and from team to team. Check your understanding – if you’re not sure what’s been asked of you (eg on a ward round), ask for clarification. Ask immediately not after another 30 patients have been reviewed. Don’t guess – NEVER guess – just because you want to make a good impression. A patient’s wellbeing depends upon this
6. Don’t forget empathy
When you’re so busy, and you’re overwhelmed, it’s easy to get caught up in process and jobs – maybe even caught up in yourself. Take time and energy to connect with patients. You may think you don’t know much, but you have so much to offer the patient. You know what’s happening, why it’s happening, and what needs to happen next. You may be the person on the team with the most time and proximity to make sure the patient knows.
You don’t need to have all the answers. They may ask how long they’ll be in hospital, or what their prognosis is. If you don’t know, be honest and say “I don’t know, but I will find out”. Patients will appreciate this honesty more than if you fluff about with a guess.
This is the part that doesn’t need you to be a rocket scientist – just be kind and thoughtful. These small acts go such a long way.
7. Own up to errors, as difficult as that may be
I’ve been guilty of trying to minimise impact of error. As a junior ED trainee, I once gave a paediatric patient four times the amount of ketamine than I had intended. Luckily there was no significant adverse effect. I still regret not owning up to it. I did tell my consultant, who reassured me that it would be fine and to observe the child for a longer period. I also told the parents but I pussy-footed about with phrases like “we gave a high dose”, “would be cautious to observe for a prolonged period”, but I wish I’d been brave enough to actually say that it was an error – and that I’d work to never make it again.
We are going to make mistakes because we are human and not machines. People will respond far better if you say “I messed up; please help me to fix it”. And the same goes for patients – just say sorry.
8. Be nice to others in your team
Being a doctor brings some kind of prestige and status, like it or not. You’re not above anyone – and never will be. Be nice to the nurses – they will make or break you. Be decent, be helpful, bring cake. If you can take a job off their hands, do it – do the bloods, change a sheet, bring a warm blanket. The nurses, allied health, admin and other colleagues will save your bacon time and time again.
9. Identify a mentor and sustain contact with them
Keep your eyes and ears open for people with whom you gel – think about what it is about them that resonates or connects with you: they may be technically excellent at their job, they may be effective communicators, maybe they are great at making their team feel safe, maybe it is that they seem to have great ‘work-life balance’ or seem content.
My own journey to finding mentors has been organic and ongoing (you’re never too old or too senior to have a mentor). Almost all of my mentor interactions are informal. Some of my mentor don’t even know they are my mentors!
I have a mentor who is exceptional as an emergency physician, but their priorities in life outside of work are very different to mind – and that’s okay. We cross paths at work on a regular basis. I have a mentor who is very reflective and provokes me into thinking about things differently to how I’m innately wired. She is not medical, but her reflections still resonate strongly. She is in the USA and we have a monthly zoom catch up.
You’ll likely end up with a ‘board of mentors’ from whom you can take away different learnings, or who you can tap in to according to what you need at the time.
If you find someone you’d really like to be a mentor, plan your request: what is it you’d like from them – specifically, think about what the objective of this connection may be; how often you can meet and where – face to face is best; virtual is better than nothing; bring coffee! Each time, come with something specific to talk about, and then end with giving yourself some homework for the next meeting, even it it’s pondering on one idea.
Don’t underestimate the value of a mentor who is not in the medical or health profession. Just like medicine has learned a lot from aviation safety and pit crew function, some learnings are transferrable and will valuable fresh perspective.
Don’t under-estimate the value of a near-peer mentor – someone who is just a couple of years ahead of you. They will likely be more in touch with the day-to-day challenges of being you than the emeritus professor who would look great on your CV as referee J
Finding mentors is a process of trial and error, hits and misses. Allow the relationship to develop organically.
10. Finally, NEVER become isolated
Isolation is a huge risk in our profession. We can gradually become disconnected from all of our networks. Because we are busy, or we work unsociable hours, or we are tired or simply not in the mood for interaction.
Isolation amplifies every negative emotion. It is the path to despair. In fact, it’s a major risk factor for depression. Avoid it at all costs.
Make the effort to remain connected, even when you feel least able for it. Meet a friend for coffee, join a social sporting team or creative group. It doesn’t need to be a hoard or supporters; just a few people you can trust and who get you. Stay connected.
I think the connecting theme through all the tips is reflection, awareness and perspective. Even the best job in the world is guaranteed to have its tough moments. When this happens, don’t ever struggle alone. While you feel like you’re the only dunce who is muddling your way through, know that you are not.
Your tough times will be offset by amazing times – be it nailing that cannula in a high-stakes resus or MET call, or connecting with a young person with chronic illness, or chatting with an elderly person with an inspiring life story.
When this happens, really immerse yourself in those moments – and then remember that feeling, capture it and bottle it up somewhere so you can retrieve it when you’re a bit down, and wondering why you even chose to become a doctor in the first place.
Remember also that Medicine is not who you are – it is what you do – hopefully ONE of the things you do.
Do it well and make it work for you – so that it can be the springboard to enjoying your life in all of its wondrous totality!
And don’t forget to have fun 🙂
