Dear Medical Intern…
You’ve finished a rigorous 5-year training process. Taken a tough exam. And stand ready to enter a new phase in your growth as a doctor.
I’ve been there – 30 years ago. And I’d like to share something with you.
To help you. To guide you. To reassure you.
And to convince you that what lies ahead is…
Your Most Important Year Of All!
In the immortal words of Mark Twain, “I didn’t have time to write you a short letter, so I wrote you a long one!”
Maybe you’re one of those who have attended my classes (in person, or lately, online) and learned about specific topics in medicine, surgery and pediatrics.
Here’s a perspective.
If these other lessons were 3 to 4 on a scale of 10, then this one is a…
Yes. That’s how much it matters.
In their book “The Fourth Turning“, William Strauss and Neil Howe talk briefly about roles of citizens in older cultures and ancient civilizations.
- The first turning lasts until age 20. Children play – and also learn the dual arts of fighting and how to grow (or hunt for) food.
- Between ages 20 and 40, a young man practices his craft – and provides for his family and people, while keeping them safe.
- In the third turning, around age 40, he switches gears. Now grown slower and weaker, his role is to offer strategic advise – and guide younger members of the tribe to do their job better, more efficiently.
- Finally, in the fourth turning, at age 60 and above, his role changes again – into one of sharing hard-earned wisdom and philosophy. Rather than telling his tribe how to fight better to win the war, he shows them it’s wiser to avoid war itself!
I’m now somewhere between the last two turnings.
So this will be a mix of both strategic advice and philosophical wisdom!
It reminds me of this man…
He’s my father, Dr.N.Sivarajan. A pioneer cardiologist, among the first 3 qualified heart specialists in Chennai, and the person who established a Department of Cardiology at Govt.Stanley Hospital.
Although he was widely acclaimed as a great teacher, over all my years of medical college there were fewer than a handful of occasions when he formally taught me something.
One of them was just as I started my medical internship. He sat me down to talk about what the year ahead meant. To me, as a person. To my career, as a doctor. To my life, as a human being.
What I’m about to share with you draws upon his ageless wisdom, layered with whatever I’ve picked up myself over the last three decades.
In other words, this is the distilled experience of two collective generations of medical practice… to inspire, encourage and comfort you in the challenging year ahead.
Your Most Important Year Of All.
In school, we once went on a class excursion to the railway factory at ICF.
One vivid memory from that trip is how a straight, stiff iron rod entered a furnace. It slowly glowed, a bright red. And then, powerful machines molded it. Twisted the thick bar into a spiral.
What had been a rather useless straight rod now became a functional shock absorber for a railway carriage. It would cushion millions of passengers over journeys of thousands of miles.
It’s the perfect metaphor for your medical internship year!
Over the next twelve months, you too will be forged in the furnace.
You will be shaped and twisted into a rather different person… one better equipped to serve, cure and comfort thousands, if not millions, of patients over your lifetime as a doctor.
No. It’s not going to be easy!
Transformation rarely is.
This is a picture of me, taken in the middle of the night, at 3 a.m. on an emergency day during our General Surgery posting towards the end of my internship year.
You, too, will work hard in the year to come. Over that time, if you do the right things for the right reasons, you will discover that it has been the best year of your life and career.
- What are the right things?
- Which reasons are the right ones?
- How will you even know if they are?
That’s what the rest of this letter is about. Let’s get on with it.
FOUR THINGS – AND AN ATTITUDE
That’s all you have to pick up during your medical internship.
The four things are what will make you a better technical specialist, and a good practitioner of your profession.
The one attitude that drives them all will make you a better doctor, and a better human being. I call this the GOLDEN RULE. It gives everything else more impact. And it begins to become established during internship.
There are also other things. They matter, too. But maybe not so much as the Top Four.
And while you’ll want to get them all right, it may not matter if you mess up the lesser ones. But if you fail at the important learning experiences, your vital year as a medical intern will have been squandered away.
So what are these Big Four things?
There’s a reason I mention this first. Without commitment, everything else means less.
In that long, long ago conversation with my father before starting my medical internship, he told me this:
“If you’re in bed with your wife, preparing to make love, and you get a call from a patient to attend an emergency, you should be ready to go – immediately!”
The message couldn’t be any clearer.
Even the most primal, pleasurable activity should be prioritized below your patient’s well being. That’s what comes first and foremost. Always.
No wonder it’s said: “Medicine is a jealous mistress”!
Over the years, I’ve had several interesting conversations with young doctors who question this kind of priority-setting. Their arguments are cogent and convincing. One might easily be tempted to buy into them.
But here’s the thing.
If you, or someone you love, needs urgent medical attention and rushes to a doctor – who places YOU on a lower priority than his or her own pleasure, convenience or comfort, how would you feel about it?
You wouldn’t want that kind of doctor for your loved one, right?
So don’t ever be that kind of doctor… to someone else’s loved one!
I know, I know… that sounds kind of naive and simplistic. And maybe it is – because right now, we’re talking about a critical phase in your training to become a full-fledged DOCTOR.
Your internship year.
During the coming 12 months (or 365 days), your highest priority – bar none! – should be your profession.
This is your acid test, your baptism by fire. A time to pit you against the world of medical practice, and see if you’re fit – or fail the test.
If at this stage in your career, without many other conflicting distractions to worry about, you cannot – or will not – show a firm, unyielding commitment to medicine, then it’s fair to say you won’t later on. Not when so many other things will compete for your attention and interest.
That’s why, in comparison to the year that lies ahead, all your earlier medical university examinations, internal assessment tests, and informal evaluations are nothing.
This right here is THE test of your mettle and determination to become a doctor.
And it’s the answer to a deeper question that has driven you to this point:
“Why did I want to become a doctor?”
Even if you’ve never quite asked yourself this over the last 5 years, you’ll likely ask it several times over your internship year. And I’m delighted for you… because every time you answer it in a convincing and confident manner, you’re taking another step towards living your destiny.
Being a doctor isn’t a job.
It isn’t a profession.
It’s a CALLING.
You are called upon to serve. To cure and heal. To comfort and relieve suffering, to your best ability.
To learn, grow, and stay humble. To get better and better at your work, so that more and more people will benefit from your care.
That begins with feeling – and demonstrating – your unwavering COMMITMENT to the task you have chosen to embrace.
The career you picked isn’t an easy one. Not always.
It isn’t fun. Not always.
But in the timeless words of Lord Lister in his graduation address delivered in Edinburgh in 1876:
“… and truly if we have nothing but pecuniary rewards and worldly honors to look to, our profession would not be one to be desired, but in fact you will find it is attended by peculiar privileges second to none in intense interest and pure pleasures.”
Yes, it is a privilege to be a doctor.
You’ll discover that when you make your firm and full commitment to its practice and pursuit. And unless you make that commitment, you will never experience the magic and beauty of a life devoted towards caring for sick people.
How can you tell if you’re committed as a medical intern?
By observing yourself.
Seeing what you do… How you think… What you feel… about events in the year to come.
You’ll be called to see a patient – just a few minutes after you get back to your room, after spending hours right there in the ward, when you’re so tired you could just sleep for a week!
What will you do?
You’ll have the hard work of hours destroyed in a moment of carelessness. A difficult i.v. line – yanked out. A carefully done wound dressing – ripped off. A painstakingly sutured laceration – accidentally scratched.
How will you feel?
You’re irritable, cranky and tired. (By the way, that’s often the ‘default setting’ for a medical intern!) A patient in distress wants you to comfort or reassure him.
Can you do it?
With commitment, you can. And will.
But without it? Maybe not.
That’s how you can tell.
And it’s how you can recalibrate your behavior over the critical year ahead. So that, by the end of it, you’ll be able to confidently answer all those questions:
“Of course, I will. I have done it!”
2. HARD WORK
A quote I read somewhere goes: “There’s enough time to rest when you’re in your grave.”
Now, a counterpoint to this may be that not resting enough will put you there sooner. But the message is this.
Hard work is an essential part of being a doctor.
Not all work is physical labor. So it isn’t fair to compare what an intern does with a manual laborer who hauls bricks or sand all day long. Much of your work as a doctor is physical. But there’s also mental and emotional work.
Caring for the sick and suffering doesn’t come without a heavy burden of heartbreak and emotional pain! Bearing that involves effort. To carry on treating your patients as they sink and don’t respond to treatment can be horrifying and hard to watch.
So know and accept that hard work is inevitable during medical internship.
Broadly speaking, there are 2 kinds of people – workers and shirkers.
Describing them is easy. Workers work. Shirkers don’t.
You’ll come across both kinds as an intern. You’ll find one dumping their work burden on the other. You’ll get angry at this, frustrated at how nobody seems to care, upset at how unfair it all is.
Here’s a viewpoint that will help.
The more you do, the more you learn.
There are no exceptions to this rule. When you do more things, you’ll get better at them. See more variations. Understand nuances better. And eventually become expert at them.
If your learning comes at the cost of a shirker, don’t complain. It’s your gain – and their loss! (If you’re a shirker, this should worry you!)
An even more important benefit to working hard during internship is that it builds the right attitude towards work in your mind. Just as regular exercise builds muscle, your attitude towards hard work grows strong with practice.
I cannot think of any branch of medicine where hard work is a disadvantage or drawback. Not even one.
True, some specialties involve more work than others. But even in ‘light’ specialties, working harder brings you (and your patients) more benefits.
Attitudes toward hard work begin in internship. They are shaped during the internship year. And at the end of it, you’ll feel this is the year you’ve worked the hardest in your life – and that it has been worth it!
So, we’ve discussed two of the Big Four:
- Hard Work
Let’s move on to the third…
Nobody is born perfect. We all work towards it.
As a heart surgeon, my hero and role model is Dr.Denton Cooley.
But I wasn’t a Cooley when I began training! Not even close.
Years and years later, after acquiring skills as a surgeon and then a heart surgeon, I am closer to his level of competence than at the beginning.
This takes incremental, intentional improvement which is sustained over many years. A process that starts as a medical intern.
Simple things will be frustratingly difficult when you begin. Starting an i.v. line may take an hour – or two! My first time doing this in the medical ward as an intern took an entire morning!
But that’s okay. Because you’ll learn and improve over time.
Soon, I was able to set up an i.v. infusion within 5 minutes – even in difficult cases. That comes from following a process:
Do stuff. Rush to follow instructions. Volunteer to do it. Even if you’re not good at it. Know that only practice makes perfect.
Observe others. Watch what they do, what they get right, what mistakes they make. See an expert do it. What do they do differently?
Think about what you did and saw. What mistakes are you making? How can you change? What should you correct or adapt?
Improve over time. Keep track of whatever you do. Conduct a personal audit. Look at how many tries you need to get it right. See how long the same procedure takes after some practice. Count how many errors or mistakes you make. Compare it against your past record.
Are you getting better? Good. No? How can you?
It’s an ongoing exercise. Even ten years later, you’ll pick up a new trick or technique to improve what you already do very well.
And this attitude, this focus on intentional practice, the self-correcting approach of auditing your own performance… it all begins as a medical intern.
Start laying the foundation for your constant growth and improvement right now.
Immerse yourself into a learning habit this year.
The morning after I finished my M.Ch. exam in cardiothoracic surgery, I met one of my professors. Dr.Joseph Draviaraj gave me this nugget of advice:
“My boy, make it a habit to read for at least 1 hour a day… for the rest of your life!“
I have tried my best to follow this ever since.
No matter how busy you are, no matter how tired, or how bored… learn something new every day.
There’s no end to studying. Exams aren’t the end, just the beginning. There’s always more to learn. And new things are being discovered every day.
By making it your core practice to acquire knowledge, right from your internship year, you’ll stay in front of the pack all through your medical career. Learning more makes you a better doctor for your patients.
This matters especially during times like a crisis, when knowledge evolves rapidly – and misinformation runs rampant. Knowing the right things can help save lives and avoid suffering.
If you try to establish a learning habit only at such times, you’ll struggle. But when your quest for knowledge is already a practiced routine, you’ll easily scale it to meet the needs of the hour.
Equally important is to…
Apply what you learn; and study what you apply.
What do I mean?
This is your chance to put to work all that you’ve painstakingly learned over your five years of medical college. To translate ‘sterile knowledge‘ into ‘fertile treatment’.
When you see a patient with symptoms and signs you’ve read about in a textbook, start drawing connections – between theory and practice.
When you make a diagnosis based on your examination and investigations, connect it up to therapies you’ve learned about – and bridge the gap between what you’ve read and what you prescribe.
This gradual process is your transformation – from medical student to doctor!
And it works the other way, too. As a medical intern working under supervision and guidance of senior doctors, you’ll often be told to do something you don’t know about or understand.
Go back and study what you applied. Do it right away. Not a week later, when your memory of what happened is weaker.
Immediately reinforcing your practical application with the theoretical knowledge of why you were asked to do it will soon make you a better clinician. You’ll have a wider database of experiences to draw upon in the future, when you’ll independently treat patients on your own.
Knowledge scales infinitely. The sooner you begin acquiring it, and the more regularly you continue to add to it, the better you become as a doctor.
And that, again, is a habit that’s formed while you’re an intern.
Finally, here it comes…
THE GOLDEN RULE
Now that we’ve talked about the Big Four things, it’s time for the Golden Rule.
Why do I call it the Golden Rule?
Because it’s so important that without it, all the other 4 are practically worthless! (Or at least significantly less valuable.)
Listen, we all agree that these four aspects of your medical internship are precious. No question about it. These are definitely the BIG four.
- Hard Work
But there’s one element of being a doctor that stands apart from all these four – and still infuses all of them with incredible power and energy.
- It can make them wildly effective at helping you care for your patients.
- It can drive you to heights of effort, tolerance and patience, ones that you’ve never believed possible.
- It can give you enormous confidence, determination and satisfaction when you develop it.
What’s this near-magical force, then?
It’s a word that you’re probably familiar with – but it has a meaning that takes some time to truly understand, appreciate and internalize.
For your patients. For their suffering. For their loved ones.
I’ve often said that I can teach anyone with reasonable motor skills how to operate on the heart. But I can’t teach anyone how to be compassionate.
That is something that wells up from within you. It’s internal. And integral to your personality.
Compassion for patients is what drives doctors to sublime heights of effort and endurance.
Without compassion for your patient, it is incredibly difficult to motivate yourself to do so many things that you’d do naturally and without hesitation when you feel it.
And compassion doesn’t spring up suddenly in an instant. It grows over time, as you engage more deeply and personally with patients. That begins usually in your internship year.
Before this year began, your encounters with patients are limited to ‘taking a history’ before you present a case to your professor in a classroom or clinic.
But as an intern, you get closer to your patients.
You’ll see them every day. You’ll watch them interact with family and friends. You’ll observe the progress of their disease or condition, see it improve or worsen.
And you’ll feel their pain.
As a medical student, you were insulated and protected by distance. You could walk away. As an intern, you cannot. You must stay – and suffer.
This can be heartbreaking. The thought of Jayaraman still brings tears to my eyes.
He was around my age, dying of an untreatable condition (primary pulmonary hypertension). No family to stay with him. Scared to die all alone. He wanted me to hold his hand as the end neared.
I was afraid too. And angry. That I couldn’t help him. All my medical knowledge, skill and commitment weren’t enough to save him.
When he died, I cried.
You, too, will cry as an intern. And that’s nothing to be ashamed of. Because it means that you feel compassion for your patient.
Channeled correctly, that emotion will help with your work.
Because there are times when patients can appear to be thankless, ungrateful, even hostile – and you must still love them!
In her essay applying to medical school, Anjali writes:
“Medicine is about so much more than science. It is human connection in its most vulnerable form.“
This should be burned in words of fire into every medical intern’s mind. You are dealing with human beings at their most vulnerable.
Afraid and anxious. Nervous and needy. Upset and unsure.
You must find it in your heart to understand and accept their state of mind. Empathize with it. Feel compassion for their suffering.
But do it without becoming paralyzed by emotion to the point that you are non-functional in treating them professionally.
That’s the tricky line you’ll learn to navigate as an intern. And when you learn the Golden Rule, it will make each element of the Big Four infinitely more powerful.
- Commitment grows stronger when you truly care for your patient.
- Hard Work comes more willingly when its purpose is noble.
- Skills are acquired with more meaning when applied for a good cause.
- Knowledge is sought as you’ll make an impact on people you care about.
Each nurtures the other.
It’s a virtuous positive feedback loop that makes you a stronger, better, more deeply caring doctor.
One who is moved to do the right things, for the right reasons, with the right attitude.
That is the essence of your medical internship year.
To transform you from a sincere, serious medical student – into a caring, compassionate doctor.
Read on for Part 2: ‘Your Internship Year – Other Issues That Also Matter‘