A recent column titled 10 thoughts on the transition to a third-year med student provides excellent advice for those entering this stage of their training, including insights from those finishing that year. Several mentioned coping with the imposter syndrome, the feeling that you are masquerading as something you are not. I would like to make the case here that the student who simply attempts to understand and help meet their patient’s needs without trying to be anyone other than who they are, need not fear they are an imposter.
When students occasionally mention to me that they feel like an imposter I pose this question to them: What do you think your patients are looking for when you enter the room that you have to fake? Often I hear responses such as “they expect me to know a lot” or “when I am asking them highly personal questions, they think they are talking to a real doctor who can help them.” Such responses suggest the student has an ideal in their head of what a real doctor is like. That ideal is characterized by expert knowledge and the confidence that is assumed to come from mastery of a field. Until you get there you are an imposter, the logic would have it….
I share with students my impression which is that what patients are looking for most when anyone enters their room is respect. Respect is not the same as politeness, although politeness is an essential component. When we respect someone we take them seriously. And when we take them seriously we relate to them as ourselves, not in a role of any sort. You never have to worry about being an imposter when you recognize that drawing on who you are may bring comfort to those you are serving.
Learning to integrate the persona of physician with preexisting self is a challenge for medical students and, all too often, I see a failure of integration. Many doctors seem to relate to patients as if they always have latex gloves on. There is a barrier there even when it isn’t necessary. Patients become some sort of breed, somehow apart from ordinary people and certainly not the same as “us.” This perspective of self versus other in the identity formation of the physician must be avoided at all costs. Avoidance comes from recognizing our shared humanity. As a wise colleague, Simon Auster, puts it: never forget that you defecate, urinate and fornicate just as your patients do (except he sometimes uses more colorful words).
It took me years out of residency to recognize that when I enter an exam room I’m just one person coming to see if I can help another. I am aware, of course, that the reason the patient came to see me the doctor is because I have special skills acquired through medical training. The extent to which I will need those skills or how best they may serve the patient remains to be determined at the start of each visit. If I really want to help that person I have to find out what is going on with them as it relates to their health. As a researcher, I’ve learned that physicians who do this effectively do not on average have longer visits. That’s because they figure out what the patients really needs early in the encounter.
I encourage medical students to offer patients much more than their neophyte clinical knowledge because they have much more to offer that patients need. I suggest that when they ask patients how they are doing, ask with the intention of really finding out how they are doing. If the patient has a chronic condition such as diabetes or hypertension, that is not well controlled, try to really figure out why. Don’t assume they just need a higher dosage of a medication or a reminder that they need to do a better job taking their meds. Chronic illness is a life challenge that comes with fears, competing priorities, costs and opportunities for personal growth. How are these impacting a patient’s health and health care?
Uncovering and then addressing these factors is what we mean by “contextualizing care.” The skills doctors need to do this well are not necessarily acquired through years of clinical practice. Unfortunately clinicians can spend decades practicing medicine without acquiring them, no matter how many facts they know and procedures they’ve mastered. On the flip side some people enter medical school having already acquired them. Such individuals are curious about what makes people tick, and know what questions to ask to pursue their curiosity. They also like to be helpful, finding satisfaction when they improve a situation. Many of us are somewhere in between. We are capable of regarding others through a wide lens, but after a few years in the medical education mill our perspective has narrowed: we are practically looking through a pinhole, both in terms of how we see our patients and how we regard ourselves.
So, if I were to propose an 11th piece of advice to third years it would be this: Rather than worrying about who you are trying to become, appreciate who you are and, in so doing, appreciate the person you are there to help.
Sage advice – well stated
Where you recommend to students (or perhaps to all would-be caregivers) “rather than worrying about who you are trying to become, appreciate who you are, and in so doing, appreciate the person you are there to help”, I see great wisdom but also real challenges.
A great many of us human beings, of any age (and most especially in late adolescence), wonder if we are really good enough and the roles, skills and responsibilities of medicine present a seductive solution to problems of wondering “who am I and am I good enough to be here?”
The ones who don’t acknowledge the nagging questions often have the most obnoxious and elaborate defenses against it. The phrase “MD means ‘medical deity’ to him” captures the physicians who have embraced that defense structure.
To truly appreciate who one is and bring THAT to bear maximally in the care we render to patients often requires some growing up, some lesson-learning, perhaps some therapy, some mentoring, some acceptance of strengths and weaknesses. This is work that Erik Erikson saw as squarely occupying the 3rd and 4th decades, and I would argue it goes on longer (but hey, that may be just me!).
The rotes and routines of medical practice, the tools and the white cloak can– for some if not many– offer a solution and a kind of bypass for all that humble work of growing up. Then, relating to patients through the pinhole of narrowly medical data collection and expertise-sharing, manages to look like a “solution”- it makes one a doctor while in effect bypassing a much more open process of trying to figure out “how can I truly be helpful given my role, my skills, and my limitations?”
We grade students with criteria that in some ways enhance the focus on narrow medical skills (“history-taking” “physical exam skills”). Those criteria are necessary but they inevitably set the entire question of the student’s humanity into a supplemental question at the end of the evaluation form.
In your recommendations I see latent tasks that are uncomfortable and perhaps to touchy-feely for many doctors to embrace (but I embrace them!):
for us to understand that it takes time to grow into one’s best self, for us to more carefully discuss the medical role and how we evaluate it with our students, and for us to actively discourage using the medical “cloak” as a substitute for growing up, for us to see “becoming a doctor” as a continuous process that involves ever-more-fluid deployment of one’s best humanity in the context of patient care.
I agree that there is more here than meets the eye and you describe it well. You begin by observing: “A great many of us human beings, of any age (and most especially in late adolescence), wonder if we are really good enough…..” I think what you are getting at is the question of whether we trust in our own basic goodness. By basic goodness I do not mean that we think we are saints who will always do the right thing. I mean that we know that we are doing our best as flawed human beings to do right by others, and will sometimes fall short despite our good intentions (and can forgive ourselves for that when it happens). If we have that basic self trust, then we can be open about who we are because we don’t feel like we have anything to hide. If we don’t have that self trust, then we hide behind the white coat, keeping patients at a distance.