American College of Physicians: Internal Medicine — Doctors for Adults ®

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Internship reflects how patient care guides medical education

From the July/August ACP Internist, copyright 2013 by the American College of Physicians

By Joshua M. Liao, MD

As I suggested several months ago in the April ACP Internist, internship is an objectively tough experience. Despite restricted work hours and educational reform, we spend substantial amounts of time in our hospitals. The depth and breadth of our responsibilities are frequently formidable. We are asked to operate under idealized conditions. If rounds proceed uninterrupted and no patients acutely worsen, and if there are no impending discharges or time-sensitive family meetings, we can function within our schedules. But as every intern knows, this is not always the case. Our energy and bodies are pulled in a number of directions, and all of this makes our year decidedly challenging.

For some of the very same reasons, however, internship can also be beautiful. We are frequently the first physicians to meet our patients and the last ones to say goodbye before discharge. In between, we are the ones who wake them in the early mornings and return later to check in and speak with their families. When they report new complaints, we show up to respond, and when they are confused by multiple comments from multiple doctors/teams, we coordinate with consultants and summarize care plans.

Dr. Liao

Dr. Liao



This proximity contributes very practically to our clinical development. Putting names and faces to diseases helps us understand and remember them more completely, and it produces patient-specific information that can guide diagnostics, therapeutics and goals of care. Perhaps equally important, however, our close patient interactions frequently produce perspectives and relationships that, for all the suffering and death, and the challenging medical and social situations, allow us to participate in the most important encounters in training.

The value of these moments shouldn’t be overlooked. On a number of occasions, I have worked with residents who, despite loving their jobs as junior or senior residents, remarked that they missed being the “front-line” people in patient care. Their new responsibilities, of knowing more patients without being overbearing or hovering over their interns, frequently made it difficult for them to build the kind of relationships they did before. Conversations with residents at other programs around the country reinforced this theme.

As I reflect on the last 12 months, I increasingly appreciate and echo those sentiments. Watching a mother of two embrace her family, just days after we pulled her back from the brink of death. Seeing an elderly widow’s unflappable warmth and steadiness in the face of fatal disease. Gripping the hands of family members as they thank me for working diligently for their loved ones, even when I couldn’t save them. Taking histories from patients and seeing glimpses of my own aging parents in them. Sitting quietly after learning of a patient’s overnight death, and pumping my fist emphatically when one responds well to treatment. These are some of my most precious professional memories, not only because they imparted medical knowledge and experience, but because they reminded me that I was present in my patients’ lives and they in mine.

To be fair, patient encounters are not always this positive, and in many situations we must extend added measures of professionalism and patience. Moreover, meaningful patient experiences are not exclusive to internship; they continue through the rest of residency and into full-time practice. But internship undeniably provides a crucible for the earliest and most intense of these encounters. It can produce memories like those above: ones that define our experience with the humanity within medicine, and ourselves; ones that invigorate and sustain our efforts; and ones we probably would not have forged without leaning in, absorbing and persevering.

Ultimately, internship is an intense, once-in-a-lifetime experience that no matter how hard or easy, or how stressful or relaxing, lasts for only 12 months. There is an immense amount to learn, not least about ourselves and our postures toward the sick and suffering. In view of that, I have a twofold exhortation for my community.

For the incoming interns, make it a point to be intentional about your work for the upcoming year. There will undoubtedly be challenges and frustrations. But by leaning into your work, you will also undoubtedly chance upon moments of profound beauty that can sustain you going forward. Internship is filled at once with the difficult and the beautiful, the challenging and the fulfilling. It also passes by more quickly than you would expect. Don’t blink.

For my peers, the outgoing interns, my hope is that we will find several moments amid our busy schedules to take inventory of our experiences over the last year. It can be easy to view internship as something to tolerate, an experience to simply get past and move beyond. But before pushing forward toward all the amazing things you will accomplish in patient care, medical education, leadership, and/or research, I hope you will reflect on the year and find (as I did) even more encouragement and motivation for becoming who you want to be.

Joshua M. Liao, MD, is an ACP Resident/Fellow Member and an internal medicine resident at Brigham and Women’s Hospital in Boston. He is also a Northeastern Region representative on the ACP Council for Resident/Fellow Members. His professional goals include care redesign and the promotion of patient safety across care settings.

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