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.