At this time of year, nearly everyone on the physician's path is in a state of transition. For many, the beginnings of medical school, residency, or independent practice are on the horizon; while others are growing from first year to second, second to third, third to fourth, etc. The process has become so standardized and structured, however, that from the moment undergraduate students make the decision to pursue a career in medicine, rigid milestones are laid before them and preparation for the next step begins.
Milestones are becoming ever more ubiquitous during our training. For residents, “milestones” now signifies a road map towards board eligibility, just as the shelf and Step exams marked the road towards matching. The competition and demand gets tougher every year, and constant preparation is required to excel at the next benchmark. But when we achieve the goal in front of us, too often there is no time to reflect on it, revel in it, or recover from it. The next milestone is immediately within sight, and our learned reflex is to resume preparation and dominate the next exam or evaluation — whatever the next obstacle may be. It's a relentless pursuit of “the next.”
“Milestones” now signifies a road map towards board eligibility.
But when does it stop? When can we be satisfied? What happens when the next test is so far away we can't see it? Or when it's not clear anymore what the next one will be? Will we know how to live for the now instead of the next? Will we be able to identify the next if it's not laid out explicitly for us?
The pre-med student studies for the MCAT, and then prepares for the interview. The medical student studies for exams, the Steps and the shelfs, and then prepares for the interview again. The resident studies for the in-service, the boards, the oral, and of course, prepares for the interview again. Even the attending prepares for recertification, sometimes another interview, and soon after, retirement. It's no wonder we burn out! We don't have the training for longevity or contentment. As it turns out, the course from pre-med to attending is not a single marathon; it's 26 one-mile sprints with no breaks in between, and we may be disappointed to find out the finish line isn't as clearly marked as we thought.
A few of my medical school classmates strategized their schedules by back-loading vacation at the end of clinical years. They decided to not take time to rest or recharge with friends and family after Step 1 and Step 2 so they could be “done” sooner. Done”¦ with what? That may have been one step closer to completion of medical school, but there is no “done” on this road. The choice for a career in medicine is a lifelong commitment, and from the very beginning we should be training ourselves on how to take the strides of a marathon, speeding up when we're falling behind pace, and slowing down when we're ahead.
In medicine the demarcation between school and a real job is often unclear to the layperson, and can leave us confused as well. Certainly you have had some form of the following discussion with non-medical family and friends:
“Well, in medical school I saw patients and did procedures, but someone was always watching me. And in residency you're a doctor, but you're kind of still in school. No, you don't go to class – well, sometimes, I guess. Yeah, you get paid, but not very much, and someone is still watching you. And fellowship is more training, but it's not residency. You make more money, kinda, but not really. Yeah, you're more of a doctor, but you were already a doctor, just not as much. But you're still a full doctor if you don't do a fellowship.”
From the moment students enter medical school, they should be able to recognize they have begun a lifelong commitment. They have started on a path that doesn't allow for weekends, holidays, or vacations like other professions do. Day one of med school is day one of their job-for-life. Graduation, residency, and fellowship are just parts of the job, parts of the choice. Certainly there's a great sense of completion when a major milestone has been reached, but to work only towards the fastest route from beginning to end will inevitably at some point leave everyone of us wondering where the end really is and where the now has gone.
There is perhaps no greater moment of the journey than residency when we should endeavor to live in the now, to make sure we appreciate each day for the lesson and experience it brings. Residency is the most critical time during which our skills and talents as practitioners are honed, and therefore when it is most important for us to avoid exceeding our pace. We'll look back and wonder how it all flew by so fast no matter how we approach it, so a slow and steady pace may make it all the more beneficial and meaningful. Slow and steady may also give us the chance to remember that the family, friends, and life we have outside the hospital walls are as real as what we have on the inside. But the outside life is the only one that will follow us from step to step and from place to place — as long as we remember to give it what it needs in return.
Emergency medicine has a long and documented history of stress and other hazards that make EM physicians more susceptible to exhaustion and burnout. Do what you can now — at whatever stage you are in today — to teach yourself how to meet the milestones the profession requires, while also maintaining a balance and pace you can sustain. Residency may be the time when we learn to think independently as clinicians, but it is also the time when we have to prepare for our independence from the path. In order to be successful at forging our own way, we have to start understanding how to live for today as much as tomorrow. And like any other skill we will learn, it takes patience and practice to perfect.