Expect the Unexpected: What It’s Like to Be a Primary Intern

The following entry was originally posted on jamesistrying.com by current NCNM student, James Munro. 

Expect the Unexpected: What It’s Like to Be a Primary Intern

Well, I’m still a terrible doctor.

Here’s a little excerpt from my journal in 2011 that I wrote while I was still working on my biology undergraduate degree:  “I think I’ve given up on being a doctor. Med school (on the ridiculous off chance that I was miraculously accepted) would be a nightmare. I hate tests. I suck at tests. That’s all med school is – tests.” Of course, I was only half right. I’m finishing up my third year at NCNM, so I did get miraculously accepted, but the endless barrage of tests is mostly a nightmare.

In the past two-plus years, it feels like I’ve learned far more about hard work and humility than I’ve learned about medicine.  There are days – sometimes weeks – when I’m convinced that I don’t know anything, that I’ll never know anything, that it’s impossible for me to succeed.  (Today, in fact, is one of those days.)

But I’ve never given up. No. Never will. I won’t even daydream about it. Because I’ve seen people do things I’m convinced are impossible. It makes me think that maybe I’m not so good at identifying impossible.  Or maybe I can be one of those people achieving the impossible.  Either way, I’m convinced it’s impossible but I suppose I’m more convinced that I’m wrong about it.

And I went from that 2011 journal entry to being about a year away from graduating with a doctoral degree.  While I was largely correct in my assumption that med school is nothing but tests, it’s not totally accurate.

During the third and fourth year, we enter the clinic as interns and get to see patients. We start actually practicing medicine. Every time I walk into a patient room, I’m gently reminded that I sit in all of those classes and take all of those exams for a very specific purpose.Irony here JM

I hate school and tests and sitting passively while someone tells me what they’ve decided I need to know. I really hate it, but I love helping people feel better and all that stuff I’m forced to smash into my brain allows me to do just that. My time in the clinic with patients inspires me just enough to get me to walk back into the gauntlet of classes and exams every day.

I started as a secondary intern (kind of a glorified medical assistant – read my story about it here) last fall, September of 2015, with extremely high expectations. I secretly hoped I was going to be some kind of phenom. I wasn’t. As a doctor, I was terrible. Always one step behind the residents, attending physicians and even the other students. Missing important points. Fumbling for terminology. That’s all okay and expected but I was really hoping I’d skip that deer-in-the-headlights phase.

A few weeks ago, I started my first rotation as a primary intern. As a primary, I am the main contact for the patient. I interview the patient, perform the physical exams I decide are necessary, come up with a differential diagnosis and ultimately diagnose the condition and offer a treatment plan. Of course, this all happens under the close supervision of the resident and attending physicians who inevitably point out all the things I’ve missed and explain why my diagnoses and/or treatments are totally wrong.

Walking into the clinic on the first day, my expectations were quite a bit more reasonable. I did not expect or hope to be a phenom. I had one goal in mind that cool, Tuesday morning – just don’t hurt anyone.

As I was reviewing the chart notes for the patients I was going to see that day, an unexpected theme came up. They were all transgender. I later realized that this rotation mostly dealt with the transgender population.

Frankly, I was terrified.

I consider myself an extremely open-minded and accepting person. I would happily do my best to help anyone in need, regardless of their gender, sexual orientation, ethnicity, race, background, etc. I like humans.

But I have to admit that I’m ignorant. I grew up on the south side of Chicago in the 80s/90s in an environment where awful racial and homophobic slurs were lightheartedly thrown around between friends. I don’t think I even heard the term “transgender” until I was in college. I spent years and years identifying and removing hurtful and oppressive words from my vocabulary because I was fortunate enough to spend time with people from all different types of populations who helped to show me the profound impact of my word choice. But my experience with the transgender population has been minimal, at best.

IMG_1259During that first visit, it was going to be my first time being completely in charge of a patient’s chart note using a super complicated computer-based electronic medical records system. The transgender patients I was going to see were on hormone therapy which adds an extra layer of complexity to the visit. I had to perform specific physical exams to ensure that the hormone therapy wasn’t causing any detrimental effects and I had to ensure that any treatments I recommended were safe with their hormone regimen.

I had all of these worries floating around in my head but, more than anything, I was afraid I still used hurtful or oppressive language that I haven’t yet identified and removed from my vocabulary. And if I still have offensive language in me, there is a really good chance it will come out during my anxiety and panic filled first shift as a primary intern.

I made a decision to worry less about doing all the doctor things right and more about being a thoughtful, conscientious and accepting person. I figured, there are plenty of people supervising me who can make sure the medical and administrative stuff runs relatively smoothly but there wasn’t anyone who could take away the pain a stupid, thoughtless comment might cause.  And I’d rather have an attending be pissed at me than make a patient feel like I didn’t care for them.

I walked into the patient room with slightly altered goals – don’t hurt anyone AND don’t say anything stupid. I introduced myself and sat down to log into the computer system while the patient was talking. I listened intently while I incorrectly typed my username and password into the computer. I waited until there was a pause in the conversation before I tried to log in again. It worked. Oh, thank god.

My first patient was a trans-female, meaning she had transitioned from male to female, and was taking estradiol, progesterone and spironolactone – a typical regimen for male to female transitions.

everyone has JMA note for people who may be as ignorant as me: This particular trans-female patient preferred to be referred to with she/her pronouns but everyone has their own preferences and it is always acceptable – polite, even – to ask how someone would like to be referenced.

During the interview, I was gathering all the medically relevant information I could but it wasn’t my main focus. My focus was on her. How was she doing? Was she comfortable? Did she feel safe? Did she sense that I sincerely cared about her? Were her medical needs being met?

We were talking about the effects the hormone therapy was having on her body. At one point, she mentioned that her thighs and butt were getting bigger. I stopped her before she moved on, “Hold on, wait, is a big butt a good thing?”

“Heck yeah, it’s a good thing!”

“Ok, just making sure, I don’t know if that’s a universal feeling.”

Then we had a short discussion about the pros and cons of different butt sizes and it prompted me to check out my own butt in the mirror later that night. Mine’s kinda small but it gets the job done and I’m satisfied with it. In case you were wondering.

The whole patient visit was like that. I was simply talking to a person who was going through something profound and life-altering and I was openly asking for clarification on the points I didn’t understand. I learned a lot about her experience while undergoing these profound changes.

I quickly made the obvious realization that every gender transition is entirely different because, of course, every patient is entirely different. Everyone has their own experiences and strengths and wisdom and problems and questions and insecurities. By not worrying so much about being the perfect medical student, I was able to get a real sense of her journey.

I missed checking for pre-tibial edema on the physical exam, a necessary exam for any patient taking estrogen, I forgot to ask a handful of relevant and important questions, I had no idea which ICD-10 codes to use and my charting was an incoherent mess. But my attending reminded me to check for pre-tibial edema, asked the patient the questions I forgot, told me the ICD codes to use and helped me edit my chart afterwards (which was unrecognizable as my own after her relentless editing).

The irony here is that my not worrying about being the perfect student doctor led to me being a far better student doctor than I would have been otherwise. Those things I missed and the mistakes I made would’ve happened no matter where my focus was. I’m still over a year out from graduating, of course I mostly suck as a doctor.

My fear of being an ignorant jerk accidentally pushed me to realize that the most important thing about being a good doctor is being a good person. I know endless facts and medical algorithms and physical exams. My brain has been overloaded with all of the knowledge I need. It’s all in there and most of it instinctively came out when it needed to in the midst of my attempt to be a good, caring person. It was great. I did way better than I thought I would.

The only things that could prompt me to bring that attitude to a patient visit would be: 1) Immense confidence in my medical knowledge – which probably won’t ever happen; or, 2) A crippling fear that I’m going to mess something else up – which luckily happened on my first day.

I’m extremely thankful I was unexpectedly thrust into a situation that terrified me so much. It immediately shaped the doctor that I’m going to be for the rest of my career.

I’ll keep reading and memorizing giant, dense textbooks and I’ll keep taking stupid exams and keep feeling like I’ll never know enough and never stop questioning if I can be successful. But the instant I step into a room with a patient, I will put all of my focus on the only thing that really matters: being a good, caring person. And I have faith that the rest of it will fall into place.

What would you like to read about next? James will address your questions, topic suggestions or feedback of any kind. Comment here or email James.Munro [at] student.nunm [dot] edu.

▪ Please note that this is not a medical column and James is not yet a doctor. Please do not request medical advice here.

▪ The views and opinions expressed here are the author’s own and do not necessarily represent or reflect the views of NCNM.