Advice for Graduating Medical Students

I’ll keep this short, since I know you’re grinding out your last weeks of medical school crushing the books for intern year instead of wasting your time on some low-yield vacation¹. But seriously, most of you are probably smarter and more diligent than I am anyway, so here’s hoping what follows isn’t totally redundant. Congratulations on completing medical school and starting your residency. The next 3-7 years of your life will probably contain the highest density of learning since your childhood.

There are loads of scare stories about starting internship (as if they’re just going to throw you to the wolves, which they might), but I prefer the more optimistic view. Granted: if your first week is on cards ICU night float or some other nightmare, things could get stressful. But…let’s take the long view. Countless others have made it through intern year before, and so will you, just like you made it through medical school. And look at the bright side: over the next few years you will see some truly wild stuff. You might see more intense or unusual things in a week than most people see in a month or a year. At some point you start to forget all the crazy stories since that just becomes part of your normal day. This is one of those jobs, like the police or military, where you get to encounter human nature in extremis, laid bare. It taught me a lot, and I trust you will find it equally worthwhile.

July 1st

1. Don’t Lie

A simple principle that can’t be stressed enough: one way or another, lying will destroy you. This is not just an ethical principle, but a pragmatic heuristic, and it’s worth repeating often. If you are too embarrassed to admit you don’t know something, it is exceedingly difficult to actually learn it. It is always preferable to admit your ignorance or mistakes than to lie. After all, it’s better your attending see you as an honest-but-behind-the-curve intern as opposed to a liar who also happens not to know what he’s talking about. If you’ve ever been witness to someone getting caught in a lie or some other dishonesty during rounds, then you already know what I’m talking about.

If you are someone for whom this might be a problem: most people go through a “lying phase” sometime in childhood/adolescence. This is developmentally normal. But, try not to let your lying phase coincide with residency (or your medical career generally). I know you have a bullshit detector, and I know you’re smart enough not to assume other people don’t have that same bullshit detector when it comes to you. Dishonesty is discovered more quickly than liars suspect, even if they aren’t confronted on their lies immediately. If the lying comes from an ego issue, just remind yourself you’re becoming a doctor, aka you’re not all that special and very likely replaceable. And, if you’re really that good at lying, there are far more lucrative professions out there for you than medicine!

2. Take Ownership

Time personally spent with the patient is the most essential ingredient of excellence in clinical practice. There are simply no shortcuts and no substitutions.

– Philip Tumulty, M.D., “The Effective Clinician”

“Take ownership”. This is common advice, and it’s good advice. The best physicians are known both to their patients and colleagues for taking ownership over every aspect of their work.

What does taking ownership look like? As an intern/resident, it can be a delicate balance. On the one hand, the buck ultimately stops at your attending, not you. On the other hand, unless you’re headed for a highly attending-driven hospital where residents aren’t given sufficient autonomy, you’ll be the one doing most of the face-to-face doctoring with your patients. This, combined with increasing pressures to practice medicine strictly by algorithm or guideline, puts a hefty premium on learning to think for oneself. You already know that substandard and flat out bad students can find ways to coast through medical school, and the same is true of residency. You don’t want to find yourself fresh out of residency too scared and uncertain to make the decisions you just spent the last decade learning to make.

So, when thinking through diagnoses and treatment plans, try as best you can to think through the entire problem as if you’re the attending physician with the final say. Try to anticipate the questions you will be asked and plan accordingly. Be prepared for meetings with patient’s families. While you don’t need to go to the ends of the earth for every patient, always consider whether you would be okay with the quality of your work if it were being done by some other intern, and the patient were your good friend.

In general, be known for stepping up and getting things done. Despite being back at the bottom of a hierarchy, one of the worst things you can do for your own learning is adopting the attitude “keep your head down, shut up, nod along, and don’t be a nuisance”. You don’t have to be as disagreeable and openly argumentative as I was, nor openly flaunt hospital hierarchy as I did from time to time. Neither am I advocating taking center stage every day, or upstaging your colleagues. What I’m saying is that if you’re the one who takes initiative when it’s called for, volunteers to do the hard work, and then delivers the goods, you will supercharge your learning and quickly develop a good reputation in your program and the hospital at large.

Perhaps the most important element of taking ownership is accepting the blame when things go wrong. When you make an error, don’t be afraid to admit it. Excuses always make you look bad. Shifting blame for your mistakes onto others is, of course, unthinkable.

Don’t forget: it should be understood that trainees aren’t perfect.

3. Know How To Complain Well

Every species fills its own ecological niche. Residents, for example, are Earth’s natural complainers. Therefore, I think it’s worth learning how to complain well.

There’s healthy complaining, and there’s unhealthy complaining. Both are distinct from constructive criticism. Characteristics of healthy complaining are: it doesn’t ultimately reduce one’s own or the group’s morale (and might even increase it); it is open to solutions to genuine problems; there’s a sense of humor, a willingness to self-deprecate and/or not take oneself too seriously, and an absence of bitterness. Unhealthy complaining has the opposite characteristics, and is easily recognizable because it is generally unpleasant to be around. Some residents turn complaining into an art, having developed a persona with a sort of dramatic entitlement complex which typically shows itself in their constantly sounding aggrieved or put upon. Consider carefully whether you want to emulate their example.

Also: closely related to complaining is gossiping. Instead of advocating a “don’t gossip” rule, which is unrealistic especially in a setting like residency, I personally try to adhere to the “only speak gossip you’d be willing to repeat to the person it’s about” rule. It’s not perfect, but it may be more effective than setting an impossibly high bar and constantly failing.

4. Keep A Patient Log

Thanks to

Adam Cifu, MD

for emphasizing this one early on in medical school. You might think you’ll never forget that crazy case of whatever it is that you saw, but you will, eventually. Keep a log of every interesting patient you come across. “Interesting” can mean rare disease, therapeutic success or failure, a particularly likable or dislikable patient, a poignant moment, whatever. Just write it down.

5. Learn From Negative Examples

We always talk about role models in medicine. While role models are undoubtedly important, I instead want to focus on those great unsung heroes of education who serve as negative examples for us, i.e. people from whom you learn what not to do, and how not to be. Pay close enough attention to these unwitting teachers and you’ll learn just as much from them as from the best mentors. Cultivating this attitude also helps prevent bitterness and cynicism during those times you find yourself working with people you don’t particularly like for one reason or another.

6. Maintain Physical Fitness

Sometimes it’s worth stating and restating the obvious: one of the surest ways to stay mentally fit is to stay physically fit. Residency can at times be mentally and physically exhausting. In my opinion, a regular workout routine of moderate-to-heavy intensity 4-7 days per week will significantly reduce the number of sick days you call in because you feel too burnt out to work. Example workouts include: 45-minutes of jogging, rowing machine, swimming, or other cardiovascular exercise; 5x5 or similar barbell routine focusing on compound lifts eg. deadlift, squat, military press, bench press, etc; High intensity interval training and functional workouts (eg. the excellent Tactical Barbell series); a stop at your local BJJ gym on the way home from the hospital.

7. Get Your Finances Squared Away

If you’re like me and keeping a detailed budget isn’t your strong point, at least have a big picture plan for your financial life. Organize and prioritize any debts you need to pay off. If you haven’t already set up a Roth IRA, 401k, 403b, and other relevant retirement investments, now is a good time. Offers on life/disability insurance premiums probably aren’t going to get better as you get older, either. At the very least, start saving for a highly liquid 6-month emergency fund and consider reading a financial/retirement planning book by White Coat Investor or something in the Bogleheads tradition.

8. Know Thyself, and Have Fun (Or: Work Hard, Play Hard)

With some effort and a little luck, residency can be so much fun. You get to save people’s lives, learn a bunch of incredibly cool things, and make some lifelong friends (and bag a hot doctor spouse). And you can finally call yourself “doctor”. Yes, it’s hard work, but part of being a mature doctor is not making a big production of how hard you work. And we know there are much harder jobs out there. You’re a resident, you aren’t storming the beaches of Normandy.

I had a wonderful time in residency and hope you do as well. I also hope that when you are finally done with residency and practicing on your own, it will have been a good enough experience that you continue to look back on it for inspiration and motivation to continue learning. We’ve never got it all figured out, and that’s what makes it so damn fun.

(Oh, and don’t forget to stay clear of the hospital sushi. But you already knew that.)

I do the same thing over and over, improving bit by bit. There is always a yearning to achieve more. I'll continue to climb, trying to reach the top, but no one knows where the top is.

—Jiro Ono, Jiro Dreams of Sushi

1. For those who didn’t know me in medical school, this is a joke.