One's own authority

One of the sobering things about the third year of residency is coming over that sophomoric high of second year, when you were finally able to start taking care of patients somewhat autonomously. Where in second year you think “yes, I nailed the management of that hypertensive urgency,” in third year you start to wonder, does hypertensive urgency even exist? Was it necessary to admit that patient to the ICU, place an arterial line, and use an iv infusion to bring down the blood pressure of a completely asymptomatic patient? You come to appreciate that you know very little, and most of what you do know is suspect.

As I transition into becoming an attending, I’ve been paying more attention to what I know and what I don’t. One of the things I’ve realized is that knowing something isn’t enough; you have to know where you learned it. A piece of information without a source is like a carton of milk without an expiration date: you don’t really know if it’s safe for consumption, and by the time you’ve found out it’s too late. Whether a pearl came from Attending A or Attending E, from a pharmaceutical rep or a published paper, it carries a vastly different weight. When you confuse where you learned something, you open yourself up to all kinds of trouble.

Ideally, knowledge in medicine is evidence based, originating from scientific studies and grounded in some type of objective, reproducible data. In reality, though, medical training is an apprenticeship; our education occurs in the work environment, at the hands of our mentors. For this to succeed, it requires our mentors to have a certain authority. We must be able to trust that when they say something, they know what they are talking about, that their input is based upon experience and knowledge of the literature. That way we don’t have to challenge every little assertion, which would be impossible to do anyway.

Even so, taking things on the authority of others only gets you so far. At some point you have to stand up and take ownership of your own body of knowledge. As an aspiring attending, that means becoming your own authority, which can entail going back and relearning everything that you know. It’s a slow and frustrating process, one that I wonder if I ever will complete; indeed, some of my current attendings still cite their own former attendings when teaching me things. Years into practice, they still do things based upon the authority of those former mentors.

Perhaps ‘relearning’ medicine is a mischaracterization, it’s really that you have to make it your own, the way a dancer first learns and then possesses choreography. You have to integrate it into the fabric of your being so that you can wield it rather than simply regurgitate it. I guess that’s what third year is for. That’s what the seventy first case of pneumonia is for – for the gelling process to occur. By working through it now and building the foundation just a little bit firmer, maybe my form will actually stick when the molding is removed next year.

posted by Wyatt @ 5:40 AM Comments: 1