It took a couple of weeks after I graduated residency this summer to finally bring it up.
"You know what?"
My husband looked over at me. "What?"
I looked at him for a moment, and then finally said the thing that had been brewing all day, slowly forming in my mind as a firm conclusion.
"I hated residency."
He half-smiled. "Yeah, we knew that."
"No. I really hated residency. Really, really, really hated it."
His smile dropped away. "I know."
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Yeah, I finished residency. I think I'm expected to say something like, "Man, there were a lot of ups and downs! It's an intense period of your life and it's really hard. But it's over now, and I'm soooooo excited to do medicine my way!" But you know what? I hated residency so much it's hard to just get over it. It feels trite to say that, because in medicine it's kind of like saying that water is wet or MIs are deadly. But I learned from watching my fellow residents that "hating residency" can mean many things; some of us just loathe the suck, while others are truly damaged by the process. No one comes out the same as they went in - we all finish somewhat better as physicians but somewhat worse as human beings - but some of us come out in pieces. I hated residency so much that I couldn't even admit it to myself properly during the process because to admit how deep my disillusionment went would be to rob myself of the stoicism necessary to endure through until the end. No wonder empathy takes a record dive among residents. If that was my introduction to real medicine then I wish I could afford to have no part in it.
But why hate residency? you say. It's hard training and hard work, but it's necessary for you to become a doctor. You learned a lot. And it was a job and you got paid. And I don't mean to ignore the good parts of the past few years. I made some good friends who I think will be with me for life. I met a few people who I consider role models. I had some funny mishaps. I found out just how well and how long I survive on minimal sleep (the answer is: a long time, but not that well). But plumbing the depths of exhaustion while learning what this profession is and is not made me question the very premises that led me to medicine in the first place.
1. Medicine is not what I wanted it to be because it is a business, you guys. It's one thing to know that from the outside in a vague sort of way. It's another thing when you have to send a nice old man with dementia to the homeless shelter because no one wants to pay for his hospital stay and his family won't take him back. Or when you realise there's a gaping hole in the safety net for those with mental illness that can only be filled by paying cash to a dubiously trained caretaker. Or when pediatricians or obstetricians or family docs or specialists won't take Medicaid patients because it "doesn't pay enough". Or when you see patients who are begging you for solutions and you have nothing for them despite living in a first-world country because they don't have any money. There were so many times that I cried at the lack of options for someone, all because of money. More money means better medical care in so many ways, in ways that you have probably never thought of. In ways that make me feel ashamed.
2. A doctor's job is not what I wanted it to be, because it's mostly paperwork, or at least it feels that way. This is especially true in primary care. About once a week during residency, my medical assistant would thunk down a thick folder next to my computer. It was full of forms for me to review and fill out or sign. FMLA, disability queries, home health updates, refill requests, Rx prior authorisations... Half the time I had no idea how to even complete the paperwork so I would just do my best and hope it was good enough. You want to know why your doctor's office has started charging for forms to get filled out? Because I would spend literally hours every week on charting and forms and calling around to places for various things. Forms do not get magically filled out by form fairies. Forms get filled out by doctors staying an hour or two late every few days to clear the backlog. I didn't even have what would be considered a full panel of patients for a primary care physician since I was only in clinic about 1/3 of the time. I cannot even imagine how much paperwork a full time family doc has to do.
3. My patients are not who I wanted them to be. I think I am a fixer. I need problems that I can actually solve. But in medicine you meet so many people with things you can't fix, or problems that are not yours to solve. I keep a list in my head - not intentionally - of all the people I met who I just could not help. It's longer than you might expect. I remember a guy who was an alcoholic; he would binge drink and then come in with a horrible flare of pancreatitis, vomiting uncontrollably and in severe pain. And yet he would leave after being treated and then come back a short while later, drunk and sick again. We offered him so many resources for quitting, and he would lie to us, and refuse... it was like we weren't even there. I saw many people like that - people locked in a struggle with their demons, grappling with them as their medical team essentially stood by and watched. There were many others who were just too sick for any medical treatment to offer much. I don't know what I'm meant to do with those people, either in person or as the haunting memories in my head.
4. My colleagues are not who I wanted them to be. Residency doesn't bring out the best in anyone, and we are all flawed to begin with. There were a lot of times when if we hadn't needed each other I think we all might have been at each others' throats, while at the same time there was a lot of irritating pretense that we were all doing okay. There were some minor and major betrayals from attendings, one of which almost cost me a timely graduation.
5. I am not who I wanted to be. Remember when I said residency doesn't bring out the best in you? I don't deal with authority very well, nor do I work particularly well as part of a team unless I am the leader. I am easily demotivated when under stress. I am absolutely certain that I was a grumpy, harsh, lousy person to deal with about half the time (and any time administration wanted me to do something). I am prone to emotionally overinvesting and then I have no way to fill that empty well back up. And I am full of selfish pride. I spent a lot of time in residency not thinking about how best to serve others but instead focused on how best to survive intact. The irony of that is that I didn't survive intact, not really. I finished residency feeling depleted, angry, and afraid of the future. Would I have fared better or even worse if I hadn't been so focused on myself? Who can say? It's hard to imagine how it could have been worse, though. I spent months at a time just getting by.
Residencies are required to do exit counselling as part of staying accredited by the ACGME, the organisation responsible for policing postgraduate training for physicians. My "exit interview" consisted of a 90 minute group SWOT session for my graduating class, a stupid and contrived format that they had clearly settled on as a way to keep people from talking a lot and thus complaining. It meant I didn't get to say any of what I wanted to say. What I wanted to say was, I gave you the last gasp of my idealism and true youth and you gave me back the ashes of dreams and a smaller version of myself. What I wanted to say was, no one told me it would be like this. If they had told me, maybe I would have chosen work that doesn't take so much more than it gives. What I wanted to say was, I have finally learned to hate medicine. You've convinced me to run away.
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Of course I don't have the luxury of running away. My husband and I are in the kind of debt that you would not believe thanks to my training; let's just say our monthly student loan payments are six times our mortgage payments. I obviously have to work. For now, I've chosen the next best thing to nothing: urgent care. It feels like I'm letting people down by doing this instead of choosing Work That Will Help People. But at this moment in my life, fresh out of training and counting the cost, I'm not sure what that work is. So I'll treat colds for a while, and we'll see. Maybe residency has just been an extended low point and I'll recharge. Maybe my questions about the practice of medicine have no answer. Maybe I'll learn to be okay with that. Maybe I won't.
