The elderly man had gaunt cheeks, blue eyes and a hesitant smile. His lips were parched, his arms and legs were thin, and there was a slight tremor in his hands. I started with the history and physical, gathering pieces of his story. Out of the woven patchwork record characteristic of many of those in their 80s, a pattern emerged. My clinical sense detected cancer before I had even seen the X-rays and labs that had made it obvious.
That clinical sense has grown exponentially during the past two years. I am now two weeks away from entering my third — and final — year of family medicine residency. In that time, I've gathered a library of clinical and intuitive data that helps me form the "detective plan" for sorting out symptoms and diseases. Some things now have become commonplace: elderly patients who have fallen, patients who have passed out or experienced chest pain symptomatic of heart attacks, congestive heart failure or emphysema. Always, however, there remains infinitely more to learn, new data to synthesize, evidence-based guidelines to review and the art of medicine to refine continually.
I am closing the door on the second year, which at our residency was best explained to me by one of my senior residents as the "workhorse year." I found this to be emphatically true. During your first year, it's obvious you are an intern. You are overwhelmed at times, feeling you have no idea what you are doing. Everyone expects that, checks in on you, makes sure you feel supported and reassured.
As a second-year resident, you're suddenly supervising interns and often making clinical decisions more independently. As always, you have an attending physician to call and ask for help. However, as with many physicians, my perfectionism, honed by my education and training process, amplifies the effects of a second year full of pitfalls, mistakes, oversights and sometimes overt criticism (internally or externally imposed). Add this to five months of 80-hour workweeks, and the end of second year comes as a welcome relief.
Despite the challenges, this year wasn't all hard work and transforming clinical insecurity to comfort. I went to Ecuador and worked with disabled children in an orphanage. There, I learned what true poverty and lack of access to medical care looks like. I saw it in the smiles of children with cavities, intestinal parasites and spastic paralysis. I spent a month in Alamosa, Colo., where I learned that rural medicine is about living within your community and doctoring to serve those around you. I spent time with specialists in integrative medicine, neurology, addiction medicine, gynecology, urology and surgery. I chose an elective, exploring the patient-centered medical home and learned how Salud Family Health Centers and Clinica Campesina strive to put a roof over the medically underserved.
My third year will involve even more responsibility. I am sure that at some point — when I look for a "real job" — I will be struck by the daunting realization that I am on my own. As a person who is comfortable making decisions by consensus, grooming my inner-physician to make confident clinical choices is like putting a square peg in a round hole. When no one is there to double-check my decisions, I may feel vulnerable, nervous and maybe, at times, even terrified. Gaining ground on confidence in my own clinical sense will be one of my tasks this year.
Tomorrow morning I will tell my 88-year-old patient and his wife that he has metastatic cancer. The sadness of the news already weighs on me. I know that it will be a lot of difficult information for the family to process, and the conversation is likely to be hard for us all.
Still, I am honored to have a job where I can touch people's lives in a meaningful, caring way.