Part I: Lacking Confidence
“What are the three drugs that can cause drug-induced lupus?” interrupted the attending physician during my classmate’s presentation on rounds. I looked at the clock. 10:30. We had been rounding on our patients for almost three hours. It was my third day since starting my third year in medical school, and I was trying to get used to paying attention to so many different patients, as everyone talked so quickly. My attending looked at my classmate and waited.
“Uh … hydralazine … isoniazid … and uhhh …” My classmate paused. My attending looked at the residents, who looked at each other and shrugged. The attending then looked at me. I had thought of the ones my classmate mentioned and vaguely recalled the third one. Was it procimide? Procainamine? Procainamide? I guess knowing the answer is just part of the battle.
“I think procainamide is one too,” I said.
“You think, or you know?” asked my attending.
That scenario was very common throughout our third year for my classmates and me, even for some of the more confident students. We were often caught off guard and asked about concepts in ways that were different from how we learned them. I often found that I knew or at least had an idea of the answer, but I was confused by the presentation or just could not think of the answer so quickly with doctors and patients looking right at me. It was embarrassing and frustrating at times, but I accepted that it was just part of learning. However, I was bothered by the emphasis placed on confidence. On many of the clerkships throughout the year, 30 to 70% of the final grade was based on clinical evaluations. This evaluation essentially encompassed how I interacted with patients, my knowledge base and my note writing. Students spend most of their time with residents, who often do not participate in the evaluations. The attendings may fill out evaluations months after the students rotate, spending little time on them and sometimes forgetting or mixing up students altogether. I often joked with my classmates that 70% of the grade depended on who the attending was, while 20% hinged on the situations we were placed in and only 10% was based on our actual performance. The most common feedback I saw in my third year for my classmates revolved around being more confident. Eventually, I learned to fake the confidence to get people to leave me alone. However, I still do not understand why the idea that medical students should be more confident is such a universally accepted concept. As a student, I felt that I should not be confident because the point of my rotations was to expose me to things I had not seen in person before. Therefore, I was appropriately not self-assured. Why should I be expected to fake it or be assertive when I truly do not know?
Part II: Faking Confidence
On my trauma surgery rotation, my resident showed me how to suture lacerations. It was my first rotation in surgery, so this was an entirely new skill. For the next patient that needed similar treatment, my resident asked me if I knew where everything was and if I felt I could do it alone. “Yes, I can do it,” I told him, trying my best to fake my confidence.
“Great, I’ll be upstairs. Text me if you need me.”
I was not lying. I did know everything that I needed and where to get it. I wrote everything down from what I saw previously. I knew what to do, but I simply had not done it before. Could you watch me get started? I did not want to accidentally harm the patient, but I also did not want to deal with the confidence nonsense from my residents or attendings. Technically, I did know what I needed to do, so I figured I would take a surgeon’s I got this approach. When I walked into the patient’s room, I introduced myself. I told him my name and that I was from the trauma team. That was the truth, though I usually introduced myself as a medical student. This time I decided the big letters on my badge, medical student, were sufficient. Does he need to know I have not done this independently before? I went to get gloves before starting, and I ran into one of the nurses who told me the patient was a “withdrawing addict” who was currently “not a happy camper,” so I was advised to avoid waking him up if possible. As I began, the patient started to complain of pain.
“Boy, finish this up and get the hell out of this room,” he yelled. I numbed the area a few times until, finally, he was able to stay still enough for me to finish. I could not tell if I was causing him pain or if he was just in pain from withdrawing, but what should have taken two minutes ended up taking fifteen. I did not realize how hard the skin would be, and I later realized that a bigger suture would have made things much smoother. This would be so much easier if I were not getting yelled at. I had hoped my first time suturing would not be on the face of a withdrawing, angry patient without supervision. As I walked out, I was disappointed with myself because I did not do a great job, but I also felt like my resident should have stayed to watch me start. My resident later told me I did a fine job and that I would keep getting better. I practiced at home, and sure enough, I continued to improve. A few days later, after suturing again, the resident said he could not have done it better himself.
Part III: Becoming Confident
Overall, I had mixed thoughts about faking my confidence and how I learned to suture. On the one hand, I was upset. I was mad at my resident and the overall system for emphasizing being confident. I felt that the patient received below the standard of care, albeit slightly, without a proper justification for it. On the other hand, I learned so much I otherwise would not have, and the patient … barely suffered? This learning would come in handy later when our team was spread thin and wounds needed to be sutured and cleaned. It allowed me to spend more time with patients and greatly improved my suturing skills.
Nonetheless, I could not get it out of my head that the first patient still had more pain, a longer procedure and a less aesthetic wound closure because of me. Are an extra 13 minutes and a slightly uglier scar a big deal? I was also bothered that this patient, essentially my guinea pig, was an African-American male from an impoverished area that suffered from many healthcare disparities. It was hard for me to believe that my resident would not have done anything differently if that patient had been sober, wealthy and white.
I think socially, people understand that doctors have to start somewhere, but many people are unwilling to be one of those patients at the start. Moreover, many are unwilling to accept that, like in any other field, mistakes or complications happen, and sometimes they may happen to you. Both these beliefs lead to decreased opportunities for students to learn, and faking confidence is what helps students get more opportunities. Unfortunately, my experience showed me that many of those opportunities tend to be on more vulnerable patient populations. What helped me grapple with that tension of wanting more opportunities but wanting to uphold the standard of care, especially for vulnerable patient populations, was that my experience on my trauma rotation was more of an outlier in terms of supervision. On my gynecology rotation, I closed more of the skin for cesarean sections each day with my team right next to me until the last day when I closed the whole incision. I had faked the confidence until it became real; in this case, I did not cause any harm to patients. As I progressed, my focus became being as prepared as possible and learning to balance faking confidence to get opportunities with asking for help to avoid giving substandard care to vulnerable patients. I knew I could not change anything about the system I was in, but at the very least, I could control my knowledge and competency. Doing so allowed me to transition from faking confidence to becoming confident, especially regarding my own learning and ensuring that patients received appropriate care.
Image credit: notebook by waferboard is licensed under CC BY 2.0.