Closing the books

It’s 5am the morning of my LMCC, my licensing exam that will determine whether or not I practice medicine this year. Moronically, I set my alarm an hour earlier than I had to. See, making 5 prayers a day is hard in the summer, when the dawn prayer sits between 3am-5am and almost certainly requires breaking up your sleep into chunks. Add that to perhaps getting up once to pee and you see that as a Muslim you barely get more than a few hours of sleep at a time, with a lot of potential to lose many hours lying in bed not able to fall back asleep.

But I guess with this time (I had meticulously scheduled to wake up for Fajr at 4:30am, thinking of how that leaves me a perfect 90 minute sleep cycle before I have to be up at 6, and wow I’m so stupid for not factoring in the anxiety and just slept til later and prayed when I woke up) maybe I’ll make the final nostalgia post I had been planning on. Suffice to say, sleep hasn’t been on my side for the past several weeks now, and as someone who’s always been out before my head even hits the pillow, it’s all very disturbing.

This is it–the last exam of medical school. The one thing left between me being a real MD. I know some people are longingly awaiting the prestige factor that comes with that, their lifelong dream being fulfilled with those two extra initials, just waiting to call themselves a real doctor. I have none of that. I’m terrified at what the responsibility of being a real doctor entails. I had no idea, none whatsoever, in first year that coming down to graduation, this is what this would feel like. I didn’t even know what I was doing in first year… I just did the medicine thing because that was what people did, and somehow it worked out for me so I just went with it. I don’t think I ever truly appreciated a moment where I wanted that MD. Now it’s dangling in front of my face and it feels like I don’t want it more than ever.

I’m excited to be a psychiatrist but terrified that that still means having someone’s life in your hands. I’ll be good at the counselling, the medication adjustment, the individual rehabilitation, once psychiatry becomes all I do. But until then, I need to get through months of off-service rotations where people will literally die on my service and I’m the only resident on call responsible for that. Nurses will expect me to order any and every medication to calm a patient, while in my head I’ll have to do the math of how much their kidneys can handle, what the attending doc will think when he sees the notes tomorrow, and if they’re getting dystonic yet for which they will need yet another medication. If I do end up pursuing a neuropsychiatry fellowship, I’ll have months of stroke call where I’m the neuro fellow, I’m the top of the ladder making the decisions, I’m the one taking RAAPID calls telling rural physicians how to manage their patients. This is all terrifying and overwhelming and nobody thinks of this in first year.

I’m going to write this 8 hour exam that supposedly prepares me to be that great generalist who can manage everything from heart block to a pregnant hypertensive to a psychotic patient. I’m going to answer what I’ve been told, the formulaic responses to all these scenarios. But I feel deeply shaken at the thought of managing these in real life (except maybe the last one) simply because I haven’t, in 4 years, developed the confidence. There are those in my class who act extremely know-it-all and are always on top of the right dose, the right intervention… and I’m still that person who’s glad to accurately make the diagnosis. I’m not at the level of saying “I’d give them x litres fluid, y medications, recheck their lytes at z time.” I still never call them “my patient” when I feel that’s reserved for the real doctors. I can never imagine actually giving a nurse orders or telling anyone what to do. I’ve never done real CPR, intubated anyone, put in a life-saving line… anything that real medicine encompasses, the flashy heroic measures on TV or what people generally consider a capable doctor should do.

And yet I’m going to be expected to do all these things. One thing they don’t teach you in medical school is the confidence required to run a team, to truly be the one calling the shots at the foot of the bed while everyone else looks to you. I want to be a good generalist, I truly do. I don’t want to be the psychiatrist who needs to consult on adjustment of antihypertensives. But somewhere along the way I need to find the courage to the boss, know that I’m equipped with the medical knowledge required to take care of someone, remember that my 4 years of training has engrained it in me, somewhere. I know I have all the answers, deep down somewhere, buried under layers of insecurity, layers of being outdone by classmates, layers of being told I’m wrong on the wards. What I’ve gotta do before July 1st is brush it off, shake off all those layers, and trust myself to make the right call.

When I titled this “Closing the books” I didn’t appreciate the metaphor of what I was going to write about. It’s been 4 years of books, more or less. And today we’ll be tested on just that–book knowledge. But the skills that make a great clinician are not teachable by books. They come with practice, and unfortunately a fair amount of mistakes, of wrong decisions, before developing the right ones. I’ve had enough of book knowledge, because I’ve used it to stay safe all these years. R1 year is going to ask a lot more of me, and maybe I’ll finally intubate and do compressions and be a hero, or maybe I’ll just finally feel confident in being a whole, generalist, basic-life-saving MD. It’s going to be a lot less safe than book knowledge, and I plan to be up for the challenge.

PS. Ugh, how adorably apt is it that I got a notification that this is my 100th post for this blog. So cute. It’s been a blast, med school. Onwards and upwards.

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