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Dear Medical Intern…

Dear Medical Intern…

Congratulations!

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…

10.5

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?

1. COMMITMENT

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 fitor 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.

That’s all!

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:

  • Commitment
  • Hard Work
  • Skills
  • Knowledge

Let’s move on to the third…

3. SKILLS

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
  • Observe
  • Think
  • Improve

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.

4. KNOWLEDGE

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.

  • Commitment
  • Hard Work
  • Skills
  • Knowledge

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.

COMPASSION

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

Safety

One man’s meat is another man’s poison.

Your idea of what’s “safe” may give someone else sleepless nights of terror!

So this is always going to be a tricky trait to define – or adopt.

Personally, you may be a risk-taker who thinks it’s safe to

go base jumping
try whitewater rafting
drive fast without a helmet
do recreational drugs
have unprotected sex
or even… be on social media!

And that’s fine – as long as it’s your personal view.

It’s important to keep in mind, though, that as a doctor… you’re playing a role.

Not being ‘yourself’.

Your role as a doctor should always be defined in the best interests of your patient.

And because all patients are not alike, and won’t have similar ideas of ‘safety’ as you, we must work from a broader, general idea of what safety means… to most people.

That way, even if you won’t satisfy all, you’ll at least conform to the perspective of a majority of the patients you treat.

Defined this way, it’s easier to decide what’s safe.

And act suitably.

Safety isn’t the same as caution, though.

You can be bold and safe. Carry out risky procedures, act daringly in a crisis, and still be safe.

Safety attempts to manage risk, and reduce the danger to everyone.

Yourself – and your patient.

As an intern, you’re placed in positions which are intrinsically risky.

You are exposed, at close quarters, to sick people. Often under sub-optimal conditions of protection or detection.

Anyone you see in an outpatient or emergency setting might harbor a deadly contagious germ.

It is critical to be constantly vigilant.

And make safe practices a routine – so you follow them without even thinking consciously about it.

As a resident in General Surgery, when I was woken up at 3 a.m. for a call, I’d stumble sleepily into the trauma ward and – on autopilot – pull on a pair of gloves before even turning to the patient.

It had become a habit.

And as we were right in the middle of the AIDS pandemic at the time, I’m sure it had life saving impact.

Safety is inconvenient.

It’s no fun to wear masks and PPE for long hours, especially in hot, humid weather conditions.

Safety is painful.

Having a vaccine hurts. Wearing double gloves makes your fingers cramp.

Safety is costly.

Disposable items are expensive. Proper protective gear isn’t cheap.

But when you contrast it against the inconvenience, pain and cost of the consequences of not being safe – it all pales into nothing!

Health is truly wealth.

So… better safe than sorry.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Get Tough, Stand Up

My all-time favorite clip from the film ‘Rocky Balboa’ begins with this:

“The world ain’t all sunshine and rainbows. It’s a mean and nasty place. And I don’t care how tough you are, it will beat you to your knees and keep you there – if you let it.”

Sylvester Stallone goes on to outline a brilliant attitude to live by – which is why I watch it at least once every few months.

It’s here: https://www.youtube.com/watch?v=D_Vg4uyYwEk

For you, young intern, things are about to change.

Drastically.

Maybe they already shifted when you joined medical college.

Outside of the safe cocoon of school life, things got a bit harsher. Became a little more dangerous.

And you coped with it.

You learned that not everyone cares as much now about your development, growth and comfort.

So you changed your expectations of them.

Now you’re on the threshold of another dimensional shift.

A sharper, steeper one.

For the first time, very likely, you’re in a workplace.

As an employee or co-worker. And experiencing the cut and thrust of everyday battle.

This section could apply to any profession. Any occupation. Because this is pretty constant across fields or specialties.

The world, indeed, can be a mean, harsh, nasty place.

And people you engage with are not always friendly or well-disposed towards you.

In fact, it’s best to count on everyone being potentially hostile – because that’s more often right than wrong!

They’ll try their best to put you down.

And how long (and hard) this continues – depends upon you.

You could react the very first time it happens.

Or wait until you get put down ten times.

Or forever.

One thing you can count on is this.

For as long as you take it, people will dish it out!

So it’s essential that you get tough.

Fast.

And stand up – for yourself, for others, and for whatever is right.

Now, I don’t advocate being a ‘delicate darling’.

Don’t get all upset, annoyed or angry at the very first hint of nastiness.

But I also don’t recommend taking abusive insults for long.

From anyone!

If somebody is being a boor – and there will be oh-so-many who fit the bill over the years ahead – you must learn to deal with it.

Firmly. Confidently. And definitively.

No, not by being nasty in return (unless you want to).

But by making it clear you won’t stand it – if this continues.

Shrinking away from confrontation is a losing strategy here.

Some fights have to be fought – and won.

Early.

And convincingly.

But before you plunge right in to a war, let me make something very clear.

You must first be sure that you’re in the right.

If you

  • don’t do your work
  • didn’t follow instructions
  • did something you shouldn’t have, or
  • were lazy, careless or wrong

then be courageous and accept your punishment.

Don’t try to rationalize your failures or shortcomings.

Don’t make excuses for not doing your duty.

Even if the retribution feels disproportionately severe for the errors you made, it’s okay.

You’re in a learning phase. Pain aids memory. You’ll never make that mistake again!

But if you tried your best, did all that you had to, and are still pulled up, scolded or held responsible for the outcome…

You shouldn’t take it sitting down.

Push back.

Assert yourself.

Defend your actions and/or decisions.

Stand up for yourself.

If you see this unfairness thrust upon someone else you know and care for, stand up for him or her.

Because not everyone is bold or strong enough to do it themselves.

And if you see a principle you believe in being violated, consider standing up for it – if that might make a difference.

I’ve said this often… practicing medicine is a performing art.

Kind of like acting on a stage.

Your stage is where you interact with patients. Perform for them.

(It’s no accident the operating room is called a ‘theatre’!)

And there’s drama in your performances.

There could be tragedy.

Even, at times, comedy.

You can be the hero.

Or villain.

Or supporting actor, playing a ‘bit role’.

Or a clown!

To be the hero, you must display character traits common to heroes. In all spheres – business or war, movies or novels, or in real life.

Courage and boldness to stand up for what you believe in comes high on this list.

You may personally be a shy, quiet, retiring person. That’s fine. I am, too.

But when it comes to your role as a doctor, remember you’re performing a role.

And if that part requires you to act tough, stand up for yourself – you don’t have any choice.

You must play the role.

Do it well.

Because the alternative is to have people around you, and the world at large, crush you to pulp.

A favorite Zig Ziglar quote of mine is this:

“Life is like a grindstone. Whether it wears you down, or polishes you up, depends upon what you are made of.”

If you’re coal, you’ll become dust.

But if you’re a diamond, you’ll glitter.

Get tough. Stand up.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Confidence

I’ll often spend 10 or 15 minutes explaining to parents the complex heart operation my little patient will require.

I go deep into the technical challenges of it. Draw pictures to show what will happen. And talk about the very real, very serious danger to the child’s life.

Many times, after listening carefully, one of them will look straight at me and ask:

“But my child will be alright, won’t s/he doctor?”

What’s going on here?

It’s not that mom or dad is dull, dumb, or ignorant.

No.

They’ve listened carefully to what I just said. Processed the information. Understand what lies ahead.

And still, they ask the question.

So what do they really want from my answer?

In a word: Hope.

Reassurance. Comfort. And encouragement.

They want me to display confidence in the outcome of a procedure that might save their child’s life – or snatch it away from them forever.

I, too, am acutely aware of these stark alternatives.

And it terrifies me.

Every single time.

It never gets easier, not even after doing it for 25 years!

And yet, despite this fear and uncertainty, I must project confidence.

Because that’s what my patients and their families need.

It’s also what YOUR patients and their families need.

People go to the movies to suspend reality, to spend a few hours enjoying the fantastic world of make-believe.

Patients come to the doctor with somewhat similar motives.

To be reassured. Given hope, and told that things will be well.

That doesn’t mean lying to them. Or offering a false sense of security and comfort.

No, that would not only be unethical… it is wrong, cruel even.

Confidence doesn’t mean ignoring facts or reality.

It’s about believing you can bend it a certain way.

Maybe you’ll succeed. Maybe you won’t.

But you can still believe.

And project that belief – for your patient’s benefit.

Look, you may have a patient with terminal cancer. It has spread everywhere. Survival chances are really poor.

You could be brutally frank and convey this to a patient, bluntly and plainly.

Or you could explain that even though things don’t look bright, we’ll try our best to fight this disease… or offer relief from suffering, and keep them free of pain.

In both instances, the patient will be fully aware of what’s coming.

But which kind of doctor would she rather have?

Which kind of doctor would YOU rather be?

Think about it.

And there’s also a lot more power in projecting confidence.

We’re all aware of the ‘placebo effect’, where how strongly a patient believes in the treatment affects outcomes.

You simply cannot overestimate the positive effect a confident physician can have on a patient’s psyche.

Dramatic, even miraculous cures are possible – when there’s confidence on one side, and a trusting belief on the other.

The mind is indeed a powerful medical weapon or tool… and a wise physician wields it intelligently.

One last advantage in projecting confidence to your patients is that you start believing in yourself, too.

When you practice being confident, it tends to rub off on you… making you more engaged, energetic and enthusiastic.

You’re known as a “can do” doctor, instead of a “Negative Nelly” who only sees the worst in any situation.

My teacher and mentor, Prof.A.M.Selvaraj, had this habit of placing his hand over the head of an anxious patient, looking right into his or her eyes, and smiling.

It was remarkable to see the transformation, as an agitated, nervous, worried face instantly broke into a wide grin or a relieved smile.

I believe healing began right from that moment.

And continued through the other steps.

Not only because of the correct diagnosis and prescription, but also because of a doctor’s confidence and a patient’s belief in it.

Be confident.

And project confidence towards your patients.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Tolerance

The lady from Kolkata asked me a few dozen questions in the course of a 20 minute phone call.

She was anxious. Understandably.

Her 3 month old baby had just been diagnosed with an Atrial Septal Defect (ASD) – a heart birth defect which was picked up by accident on a visit to the well-baby clinic.

The child didn’t need any treatment right now.

Maybe after 4 or 5 years, things would be different. But not now.

Still, she was worried.

I did my best to reassure her.

A month later, her brother-in-law (who is my friend, and referred her to me in the first place) called to let me know… that she had fixed a date for the baby’s operation next month, with a different surgeon.

This isn’t unusual.

It’s easy to get frustrated with people who do this.

Ignore your prescription. Reject your expert advice. Disobey your instructions.

And other kinds of nonsensical things.

Yet tolerance is an important virtue for young doctors (and old!)

Why do we tend to be intolerant, though?

It seems like we’ve somehow imbibed a kind of wishful desire – to see perfection everywhere.

In our politicians. In our parents and children. In our co-workers and colleagues.

And in our patients.

But we live in an imperfect world.

We are all flawed, just in different ways. And accepting this reality makes us more understanding of others’ shortfalls.

Your patients will be different from you.

In many ways.

In their personal behaviors. Or philosophical attitudes. Or beliefs.

In lifestyle choices. Moral standards. Civic sense and responsibility.

In their political preferences. Religious persuasions. Cultural mores.

And many, many more ways.

That shouldn’t mean anything to you, in a professional sense.

You don’t have to like, approve, or endorse whatever your patients do (or did not do) in order to treat them.

You should learn to look past them to the patient, the human being in pain, who is behind it all.

Treat that person, ignore the rest.

Or make allowance for it.

This is what I mean by practicing tolerance.

Your personal principles and values are your own. By all means, cherish and respect them – for yourself.

But these things should have no impact on your PROFESSIONAL self.

That goes beyond to the core of what you do as a doctor… heal patients, save lives, promote health.

As I already mentioned in the discussion on professionalism, a pro is someone who ‘gets things done – no matter what’.

Being tolerant of your patient’s very human foibles and failings, as well as your own as an imperfect, imprecise doctor, is vital…

For your own peace of mind.

And for performing your role as a doctor, with uniform competence that approaches excellence.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Nurture Humility

“You ask me if I have a God complex,” sneers Alec Baldwin, playing a heart surgeon in the film ‘Malice’. “Let me tell you something…. I AM God!”

He set the bar high for self-aggrandizing blasphemy!

Watch the clip here:
https://www.youtube.com/watch?v=-TRjR7vzMhA

We’re constantly being told to be humble.

Even as a child, folks told us that arrogance is bad, even evil.

But here’s the thing.

The arrogance of ignorance is indeed a bad thing.

However there’s a form of ‘arrogance’ that stems from being really, really good at what you do.

And that’s not always undesirable.

Arrogance backed by competence is really confidence.

And that kind of confidence helps make you a better doctor.

I’ll go even further.

Without such ‘arrogance’, you’d even hesitate to do your job – because what you’re involved with every day as a medical doctor… messes with the natural order of things.

Your work intentionally interferes with powerful forces of Nature.

Flaws in development. Ravages of invisible germs. Effects of unknown carcinogens. Age-related changes. Conception and pregnancy.

All of these are targets of your efforts – to heal and save lives.

Imagine a surgeon picking up her scalpel, ready to operate on a birth defect, or a cancer, or a badly damaged organ… knowing that her intervention will alter her patient’s destiny forever.

Do a good job, and it will be fine.

Make a mistake, however, and it all ends right there.

How can she even proceed… without a confidence that borders on arrogance?

She can’t.

You can’t.

So why is this advice to practice humility even relevant?

Here’s why…

Many years ago on our daily morning rounds, twenty of us doctors crowded around a bed in the cardiac ICU at Great Ormond Street Hospital in London.

The tiny newborn was on her fourth post-operative day.

We still couldn’t get her off the ventilator. Several people offered opinions.

As one young lady began to speak, the ICU consultant cut in and presented his view.

Prof.Marc de Leval, who was the Director and Head of the program and a pioneer heart surgeon (he wrote the definitive textbook on congenital cardiac surgery…in the year I was born!) listened quietly.

Then he pointed to the junior doctor and said, “You had something to share?”

She was a final year undergraduate medical student, visiting for 2 weeks from Michigan, USA. Just before this, she had spent some time as an observer at the cardiac surgery unit there – and seen a similar case.

She explained what was done.

“Let’s try that,” said Professor.

Next morning, the baby was off the ventilator!

Only because the most experienced heart surgeon in U.K. had the humility to listen to a student – who hadn’t yet even graduated as a doctor – a child was now alive.

That’s the most powerful lesson I’ve ever had in the importance of humility.

By all means, be confident.

But never let that confidence destroy your humility.

I don’t care how good you are, how talented, skilled or experienced – you will make mistakes, create complications, and lose patients.

You will sometimes run into situations you cannot handle, and face problems you don’t know to solve.

Unless you are humble, you will not learn from those mistakes and experiences.

And without such learning, you cannot grow and improve as a doctor.

An over-confident doctor grows careless, irresponsible, reckless… and then, becomes dangerous.

An arrogant doctor doesn’t heed warning signs, or accept errors in judgment, or anticipate potential crises… and that is harmful to patients.

So stay humble.

And be watchful.

But also keep striving for competence – and confidence.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Decorum and Poise

At least twice or thrice every year, when I was in school, the law college hostel became a hot spot.

Riots broke out. Buses were hijacked, even burned. Shop windows were shattered by rocks and soda bottles. Storefronts shuttered as violence erupted.

For a while, we lived near one of the city’s most infamous arts college.

From our balcony, I watched groups of boisterous students take over buses. Evict all passengers. Instruct the driver to park by the roadside. And then clamber on to the roof and dance – while colleagues sounded a chorus on the bus horn!

Any attempt by authorities to thwart their fun could become an excuse for a flash strike… and all traffic came to a standstill on the busy arterial highway.

Medical college students weren’t permitted such ‘self expression’.

Not by any law or rule – but by something more powerful.

By an unwritten code and convention.

And by the dignity of our profession.

Because we are… doctors.

Right from the moment you step across the portal of a medical college, you begin subtly imbibing into your system the realization that you’re a part of a unique group.

A rare subset of people who deal with esoteric and wonderful things.

Like people’s health and well-being.

Like society’s wellness and vibrancy.

Like making life and death decisions – literally every day.

You also realize quickly that you’re now expected to conform to a higher standard than most others.

Just like generations of other doctors did before you.

Even strikes or protests were dignified and decent. Hooliganism was strongly condemned. Political discourse on college campus was lukewarm and polite.

It was good preparation for a career in which your adherence to decorum and dignity, and your maintenance of poise and polish, are so critical to the proper performance of your duty.

This doesn’t mean that you’re weak and spineless.

Quite the contrary.

It’s meant to display strength through calmness. And convey this sense of power to others… by how you behave.

It also has an enormous impact on treating patients.

Just think about it.

If you went to the doctor with a serious health problem, and find him agitated, excited and in a panic after examining you… how would you feel, as a patient?

On the other hand, how would a calm, composed professional, who explains your situation and outlines a plan of action in a soothing voice, make you feel?

To stay calm in the middle of a crisis, to control your tone and emotions, to convey a sense of confidence and authority – isn’t really easy.

Especially when you’re aware of the danger or seriousness of a situation.

And yet, patients deserve your reassurance.

Even a dying patient rarely wants to hear that her case is hopeless, that nothing can be done.

They look up to you.

Their families turn to you.

And that’s why you should be able to always project a calm, composed, confident exterior.

Such poise and confidence doesn’t come by accident.

It’s the result of long, intentional practice.

Medical doctors get started early. Even while in training.

Because fairly or not, society holds doctors to a higher standard.

And we’ve got to prove… that we’re able to live up to it.

Since we live in a meme culture, maybe this will resonate:

Stay calm – and save lives!


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Work Ethic

Groggy after a long night on duty at the hospital, you stagger sleepily into your room.

Too tired to take a shower or even eat, you drop into bed.

Within seconds, you’re out like a light.

A few hours later, you awaken dazed and unsure. It takes a few moments to reorient yourself.

And then, you doze off again.

When you finally wake up and glance at the clock, you realize that it’s almost time to get back to work.

This is typical of how an internship year at a busy hospital goes.

So when I tell my young friends that “this is the easiest it gets”… they simply roll their eyes.

Surely this guy must be kidding, they think.

But I’m not!

It really does keep getting harder.

You see, work has different components. Several dimensions.

There’s physical work, where you perform the laborious tasks. Like collecting and delivering blood samples. Or doing dressings. And assisting at surgery. Seeing patients in the emergency unit. And more.

But there are also other kinds of work.

Like mental work.

And emotional work.

They don’t look much like ‘work’… but are infinitely harder.

It’s one thing to prepare a vial of Meropenem and inject a patient with it every 8 hours.

It’s another thing to make the decision to begin treatment.

While the first takes time and physical effort causing some inconvenience and discomfort, it pales beside

  • the mental effort of deciding when and what to prescribe, and
  • the emotional effort of facing up to what happens if you’re wrong

As an intern, the latter decisions are made for you.

You won’t have to live with the consequences of those choices.

It’s one thing to tackle the boring documentation of case notes that detail the last hours of a patient who has succumbed to illness, or not responded to your treatment.

It’s another thing altogether to break the news to a grieving family. Or to answer their questions with compassion, or assuage their guilt, or respect their sorrow. And to share with them in loss.

Most of the time, you won’t be called upon right now to do this.

But somebody will.

And it might appear as if that person has got it easy – when they really don’t.

It’s only later on in your medical career that you realize that these days, when all you were stuck with is hard, demanding, exhausting physical labor… were really the easiest part of your professional life!

Now, this isn’t meant to scare you.

Just to prepare you.

By the time you arrive at the position where you’re the one making those decisions, you will have acquired enough knowledge, experience and wisdom to make them well.

It doesn’t mean the job gets any easier. But you’ll be better prepared for it.

The reason for telling you this today is so that you get used to the idea of embracing a certain work ethic as an intern.

Everything you do in your professional capacity as a doctor is directed at your patient’s well-being.

Or at society’s improvement, indirectly.

It’s hard work.

Challenging, exciting and important, yes. But also hard work.

Even if it appears (to you) that things get easier as you become a senior doctor, that’s only an illusion.

It’s a true dictum in medical practice that your work is always the easiest it will ever be – right now.

From here, it only gets harder.

Be mentally prepared for that.

Get emotionally stronger to face it.

And be willing to embrace your reality.

It will make you a better doctor.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Respect Privacy

Oooh, you just can’t wait to tell them all about it.

That titillating tidbit. The funny incident. All that yummy (or yucky) news about what’s going on in the hospital.

It seems such a thrill to regale your friends and family with anecdotes.

Sharing juicy gossip, after all, is fun.

But as a doctor, you must also learn discretion.

Define clearly the thin line between innocently sharing information – and the deadly mistake of violating patient privacy and confidentiality.

The bond between a patient and doctor is special.

Even sacred.

It’s like discussing things with a moral authority (like a priest), or a legal one (like your lawyer).

Your patients will reveal secrets to you – that they would never dream of telling anybody else.

And the reason they’re doing so is because you need this information – to treat them more effectively.

To cure their disease.

To ease their pain.

To solve their problem.

That’s why they are willing to overcome their natural reluctance to tell others these embarrassing, intensely personal and potentially incriminating truths.

That’s also why your professional code of ethics is so stringent about preserving their privacy.

You are duty-bound to honor their trust, and keep all your patient-related communications confidential.

It is a trust you dare not violate – without the risk of ruining your reputation.

And maybe even being sued for malpractice!

What’s the big deal, you may wonder. But it could indeed be a big deal for some patients.

That’s not for to you to decide, anyway. Just uphold their right to privacy, and respect their wishes.

Social media opens up a can of worms.

Some doctors blithely share photographs online. They unthinkingly reveal intimate details about patients, often in ways that permit identification of individuals.

That is wrong.

Just because no serious criminal case has yet been filed against a doctor for such egregious violations of confidentiality doesn’t mean that it’s okay to do this.

It is not.

There are very stringent guidelines governing how, when and where you can share patient-related information – and the mechanisms to follow while doing so.

Get familiar with these rules.

Follow them.

And preserve the integrity of your position of trust.

Always respect the privacy and confidentiality of your patients.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Forgiveness

A tiny toddler struggles to her feet – and tries to run to her mother.

She takes a few shaky steps, then stumbles.

And falls to the ground.

She sits there, crying.

Now imagine what would happen if her mum walked up to her…

And slapped her on the face – for falling down!

Isn’t that stupid?

And silly?

Even cruel?

Of course it is.

It’s not the child’s fault that she tripped and fell!

Give the child a few more years. Or even months.

As she practices and grows stronger, learns how to balance and co-ordinate her movements, she’ll get better.

Pretty soon, she’ll be running all over the place – forcing mom to be constantly on the look out.

That’s exactly how we all learn.

Until then, it’s important to be patient, understanding, and forgive any mistakes.

But…

What has this got to do with you being an intern?

Well, on some level, you, dear intern, are a toddler too.

In the long path to becoming a doctor, you’re still taking your first few baby steps.

Not surprisingly, you will stumble and fall.

You’ll make mistakes. Not know what to do. Or how to do it well.

Should you be held to account?

Punished or scolded?

Is it even reasonable to expect someone barely starting out as a doctor to behave perfectly?

Certainly not.

Which is why you shouldn’t expect that – of yourself!

Forgiveness for your own failings, shortcomings and limitations is important to develop early.

Can’t draw a blood on your first attempt? It’s okay.

Forgot to take a simple precaution? That’s alright.

Feel silly about that glaring oversight? Don’t worry.

You’ll soon get better at it.

Often, others will forgive you for mistakes. Often, you are the one who will be too hard and harsh on yourself.

Don’t be that silly, stupid, rude mom of a toddler who falls down while learning how to walk.

Learn forgiveness.

Practice it on others.

But first, upon yourself.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.

Come To Terms With Death

Aayiram paerae konnaven arai vaidhiyan”
(One who has killed thousand people is but half a physician)

There’s a grain of truth in this pithy quote.

Every doctor in training is grimly aware of it.

In your chosen profession, mistakes can be costly.

And yet…

Death is the common destination we all share.

It’s true that we often have such complex feelings and attitudes towards death.

For many interns, this year will be your first intimate contact with death.

It can be scary – if you let it.

A lot depends upon your previous experiences with such loss. It conditions the way you feel about people dying. And it influences how that affects you.

Everyone dies.

You and I will die, someday.

And your patients, too, will die.

At times, despite your best efforts. And rarely, because of them.

Look, no doctor likes losing a patient.

And yet, it happens.

You’ll make errors of commission – when you did what you shouldn’t have.

You’ll make mistakes of omission – when you didn’t do what you should.

It might end in death.

It’s easy to get trapped in a never-ending ‘blame game’ and hold yourself responsible – in a self-defeating way.

But if we’re being completely honest, there’s no way to be absolutely certain that what happened was a direct (or indirect) result of your actions, decisions or choices.

My first thyroidectomy patient died – on the night she had surgery. For the next 18 hours, I bitterly blamed myself… until the autopsy report showed a massive pulmonary embolism from DVT.

Not every death is followed by an autopsy. There’s no way to confirm every detail.

And so we can never know the extent of our own part in the outcome.

Or if things would have been different. Or whether the result could have changed.

Maybe it could… or maybe not.

That’s why it doesn’t help to keep beating yourself up.

Instead, learn from any mistakes. Decide to never repeat one. And move on, determined to be a better doctor.

In the immortal words of famed French surgeon Rene Leriche:

“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.”

I have my own. So does every doctor.

You will have yours, too, in time.

Use it to learn lessons. To make promises. And to grow as a physician.

Respect death. Don’t fear it.

Fight death. Don’t hate it.

Come to terms with death and dying.

It’s difficult, but necessary.


Have you read Dr.Sivasubramanian’s books on the making of a surgeon yet?

Read the other ‘Desirable Traits for Interns‘ here.