Turning back the doubts of Imposter Syndrome and sense of not belonging in an ED.
The first patient I introduced myself to as a “doctor” informed my attending when they went to go evaluate the patient that they had not been seen by a physician all night. In all fairness, I must have looked quite nervous and far from professional as I adjusted and readjusted my stethoscope around my neck, wrote notes on scraps of paper as the patient talked, and left the room only to return moments later and re-ask questions the patient had already answered.
Just like my peers, we had all worked so hard for so long to call ourselves physicians. But my initial execution of that title, and all the times after that first time, have fallen far and low from the expectations I had set for myself. We’d all been told too many times to count that Imposter Syndrome hits you like a cement truck from the first day of intern year onwards.
What I had not realized was that it should be equated instead to a cement truck hitting you every single day, multiple times a day and in between every patient. It is incredibly exciting to go into each room and think “every patient here is so different!” But also challenging to carry all those patients together at once and realize “every patient here is so different.” It takes your mind running at a million miles an hour while simultaneously moving at a precise and methodical pace. I still have so much to learn and so many ways that I need to improve.
During my first few shifts, the nurses had to come to me several times a night, reminding me to actually place the orders I said I would put in. The first few consults I made informed me that it was “better practice to get an actual workup done before reaching out to them with empty hands” and then proceeded to hang up the phone.
The first time a case manager called me and I could not answer any of their questions regarding a patient that had been passed on to me by the team before, they frustratingly said “saying that you received a patient from sign out does not excuse you from knowing their history and hospital course.” I cried in the bathroom after we hung up. They were right of course, but it felt like a re-wording of the same concept that continued to pound through my head every minute of every shift, after every encounter: “you do not belong here.”
A few weeks back, I had what felt like my biggest loss of residency so far. I think about it at least once every shift when I feel overwhelmed and rushed, in a hurry to get to my next patient. Reminding myself of the encounter grounds and humbles me. The patient came in with vision loss in his eye following a stressful game he coached.
He tells me he had “severe acid reflux” and tried to vomit several times during the game until he suddenly lost vision in one of his eyes. I had 10 active patients and a lac that needed suturing in triage, and he told me it was similar to a previous retinal detachment he’d had. I did not press further about the acid reflux, did not delve into why his systolics were in the 220s other than to ask if he’d taken his evening blood pressure medication, quickly evaluated his vision, and whisked myself off to consult ophthalmology.
In between, I ran over to fix the laceration, and on my walk back over to the main ED, I found my patient moved out of his room and into the resuscitation bay, surrounded by people. I walked over, mouth gaping and was met by my attending handing me his EKG. Sky-high ST elevations covered the page, cardiology fellow already calling his attending, ophthalmology standing far, far back from the scene. A full-blown MI.
I heard my attending say, “his acid reflux was in fact tearing chest pain” and felt myself turn red and start to sweat. Why hadn’t I taken a few more moments to really and truly assess this patient the way I’ve been taught to? Would the true explanation for what was wrong with him have been staring me so obviously in the face the way it was now? Would I have placed a higher priority on a minor procedure over what could have been a disastrous outcome?
At the end of that shift, as I made my final visits to each patient before signing out, I came to him last. He looked me in the face and said in earnest “thanks so much for taking care of me tonight, doc.” I did not tell him in that moment that I had failed him incredibly. That his disposition did not end in demise, no thanks to me. My attending joked at sign-out that we should get EKGs on every patient who comes in with vision changes. Everyone else laughed along but I left the ED, walked back to my car, and whispered to myself “you do not belong here.”
Though difficult as that shift was, as terrible as I felt for a few shifts after that, it brought me to the realization that 1) I was human but more importantly, 2) so were my patients. So were the individuals placing their full trust that regardless of what insecurities I had about my own experience, they were receiving care from a physician who wanted to provide the absolute best patient care to them.
Even if the move towards that took time and work. That is where the fantastic nursing staff, case managers, adjunct healthcare providers, and my attendings have helped me fill in the gaps. To remind me to place orders and facilitate care first, and then work on documentation. To remind me that just because I receive a patient at sign-out, does not mean I am excused from taking them into my care and knowing their history. Lastly, to keep pushing forward, learning, evolving, and very importantly, knowing when to turn for help.
My 20th patient found themselves in front of someone who had a good idea of what workup they wanted to be done and an idea of the options for treatment. My 50th patient, the “M-eye,” saw me miss a critical portion of their exam, necessitating my attending to step in and take charge. All this work, all of these failures, so that my 100th patient never knows that the person in front of them made several mistakes to make better decisions for them, providing them the best care I can provide.
I am getting better, my peers are getting better, and we are all moving on and up. One day at a time, doing my absolute best to remember with each patient I take under my care, “I’ve worked hard to be here, I deserve to be here, I belong here.”