SECURITY IN INSECURITY

K. Patrick Ober, MD                                                                                                                                             April 24, 2015

A number of years ago, when I had the authority to do such things, I had the privilege of giving senior medical students their final medical school assignment. I didn’t want it to be trivial. I didn’t want it to feel onerous.

The graduating students were all thinking into their futures anyway, and so I decided to let them flush out their thoughts in a little detail. I asked them to write a letter of advice to themselves – the future doctors they were going to be during residency, two years into the future.  I wanted each student to take stock of his/her current situation, and to reflect upon the good and the bad things encountered so far in the journey to being a doctor.

The assignment was vague, purposefully, and was intended to provoke some reflection. [“How have you changed as a person in medical school?”…“What characteristics have you seen in the best doctors that you aspire to emulate?”…“What behaviors do you want to avoid at all costs?”]

One of the things that most surprised me, in this highly qualified cohort of fledgling doctors, was a frequent confession of profound insecurity. In one of the recurring subsets of the theme, one student expressed some self-doubt about whether he was truly capable of being an adequate doctor, as he discussed his doubts with his two-years-in-the-future self.

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How does it feel to be a real doctor?

I never really felt like a doctor during medical school (well, you know that), and I sometimes wonder if I ever will.

From this side of things, I just feel mostly…well, inadequate.

I think that maybe I was an okay student, but I’ve never been sure if I was going to be a good doctor.

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This sentiment was more pervasive than I had anticipated. One student went so far as to actually apologize to her future self, anticipating the pending implosion of her residency as soon as her medical student bluffing and false bravado were discovered.

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At this point I can only assume that the deficiencies I tried to hide from my interviewers over the past few months have been uncovered.

I’m sorry…

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Here is something else I found out. Insecurity is not a phenomenon that waits until graduation to declare itself. The insecurity starts from the beginning of medical school, as another student wrote.

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Remember when you were about to sit down and take that first test in anatomy and you were scared to death?

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I was taken aback by the varied expressions of self-doubt. I knew these senior students. I had interacted with each of them. They were well-informed, hardworking, accountable, and highly motivated, but the doubt was there from the day of acceptance into school.

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When I was first accepted to medical school, I was worried that the administration would figure out that I was a fraud, and that I really did not deserve a seat.

However, I became fairly self-confident during the first two years, and felt that I was worthy of my position.

This notion, of course, was shattered during my third of medical school.

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At first, I was stunned by the prevalence of the sentiment. Although my assignment to the graduating students could have been completed superficially, if not blown off altogether, there was striking thoughtfulness and frank honesty in the reactions I received.

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Now that I’m close to graduating from medical school, I’ll admit that I don’t feel like a doctor, at all!!!

And that I am certainly frightened by what residency will bring.

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Here is what else caught my attention: not only was there more insecurity that I had anticipated, but it seemed to be associated with the feeling of being alone in all of this doubt, combined with a suspicion that no one else in the class had similar reservations [which was, presumably, the reason no one had ever talked about it].

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I remember my classmates in medical school commenting on how, by graduation, they had learned so much and become so much smarter.

It seemed as though I alone felt somehow deficient and overwhelmed with everything I did not know and had not learned.

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Most of us suffer, in one context or another, from the “imposter syndrome” – the feeling that “someone made a mistake by choosing me and I am not supposed to be in this enviable place, and now I have no choice but to bluff my way through it.” The syndrome is usually associated with a sense of inevitable doom – “no matter how well I bluff, I will eventually be found out, and it will be the greatest embarrassment of my existence.” The sense of inevitable discovery can even create a perverse desire to be found out earlier rather than later, to shorten the interval of painful anticipation. Otherwise, as one student observed, recurrent bluffing can create new deficits of its own.

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Medical school taught me how to be confident in what I say even if sometimes I have no clue what's going on, and as an indirect consequence decreased my patience with people and hence my listening skills.

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The good news here is that all good doctors, no matter how long they have been out of medical school, are insecure. They fear their histories aren’t thorough enough, their examinations are not meticulous enough, and their clinical reasoning is not insightful enough. Through their insecurity, they become more attentive, more open-minded, and more flexible. The reality is that experienced doctors – if they are any good – worry in the same way that a graduating medical student worries.

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I guess I do have some concerns about the coming years. In fact, if I could just have one hope, it’s that while you’re reading this, you still actually are a doctor.

Well, I guess that’s almost a given…how about a good doctor?

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Here is an important thing I have learned by watching doctors and patients through the years. Patients don’t want to have completely confident doctors. Confident doctors don’t double-check. They don’t doubt themselves. They don’t look things up. They don’t ask enough questions. And if they don’t do those things, they are arrogant doctors. And arrogant doctors are bad doctors.

The best doctors worry, and they worry a lot. Here are the words of a worried student who is on the way to being a superb doctor –

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As I move one rung up in the ladder of my medical training, the words “first do no harm” become more real to me, for the potential to do unintended harm has been increased by my increased responsibility.

Am I fully equipped to do no harm?

Do I have what it takes to provide the best care for my patients?

Once again the voice inside of me tells me, “You can do it, you have what it takes.”

I still have my doubts and I hope that inner voice turns out to be right.

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We should bask in our insecurity! It is universal among good doctors. If you meet a doctor who never lacks in confidence and never has self-doubt, run away.  He is either arrogant or lying or insane. [Don't loan him your car, and don’t let him take care of your mother.] One of the graduates succinctly put it this way:

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Hubris makes for bad medicine.

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Another graduate, also open with his insecurity, thought of something that seemed more important than the advice he was giving to the doctor he would be in two years.

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I would love some advice right now.

I sort of feel like I am about to jump off a cliff with a hand glider and that I have no thoughts as to where I might land.

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I felt good about all of the insecurity in our graduates. I never have to worry about them being good doctors as long as they are worried about being good doctors! The worry itself forces them to be good doctors. Every outstanding doctor I have ever met worries every day whether he or she is any good at doctoring. And it is the worry that makes each of them good. The essence of the idea is captured in this advice from a graduate to his future self…

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Be the type of doctor you respect and admire:  

the one who agonizes over the differential,

who researches the literature,

who does a second physical exam if something doesn’t seem right,

who takes a little extra time to prepare for rounds.

Do your best to not do anything half-way.

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So, if you are a student…just keep feeling insecure.

It is the best tool you have for being an outstanding doctor.

[If you are already a doctor, you already knew all of that.]

 

 

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