“It is easy to see the beginnings of things, and harder to see the ends. I can remember now, with a clarity that makes the nerves in the back of my neck constrict, when New York began for me, but I cannot lay my finger upon the moment it ended.”
– Joan Didion, Goodbye To All That

So it feels at the end of residency. Of course, there is a graduation date. However, the emotional jolt of starting intern year contrasts with a nebulous crawling sensation at the end. Residency seems to taper in repetitive, small appreciations that each teaching moment may be the last.

First came the final shift on inpatient medicine. I stood at the threshold of 6 West hospital floor and marveled that the sense of foreboding three years ago had given way to familiarity and, though hospitals can be quite dangerous, safety. Goodbye, 6 West.

Then my last ER shift passed. The other senior and I traded laughs over mutual flight anxiety between seeing patients, and suddenly it was over. Goodbye ER.

A month later I pressed my fingertips on a baby’s soft skull as she crowned. Her mother was experienced and calm:  the opposite of birth’s portrayal in Hollywood. It was relatively quiet as I lifted her to her mother’s chest. The placenta delivered and we replaced the bedclothes, tidied the room and congratulated her once more.

“Thank you for being here,” the mother called as I reached the door. Looking over my shoulder, she was cozily wrapped in off-white blankets, holding the blue and pink striped baby bundle on her right shoulder under her chin. The sun was just rising through the right wall of windows. It was an image of love and new beginnings. Goodbye, labor floor.

This month thousands of residents will wrap up their training. Some proceed straight into fellowships the day after residency. Many, myself included, will begin their first attending position. We have begun packing, taking last hikes with friends and reflecting on what it means to say goodbye.

Some of the hardest goodbyes are to our patients. This will vary across specialties but for family medicine in which continuity is paramount the experience is especially poignant. Studies show that patients suffer when a primary care provider ghosts out of clinic without warning. They feel understandably betrayed or abandoned. They fear they will not connect as well with the next doctor.

And, strange though it would feel to say out loud to them, I feel afraid too.

Like my patients, I am afraid to let go of the doctor-patient relationship we’ve built together. As doctors we frequently describe care as taking our time and finally, in ways I could not understand before spending years with them, I value the time my patients have put into me. In this place where I’ve come to feel safe, to laugh sometimes and to practice being intellectually and emotionally present, I need to thank my patients for being here.

Every time I have shared a plan and needed to repeat information or speak slower my patients were teaching me. Every time I led the goal of care discussion and patients seemed to deflate before me, or become angry and dissent entirely they were helping me understand fear and vulnerability. And every time a patient met their newborn or split into a grin after hearing good news they reminded me of their hope and trust in life.

I am grateful to them.

Holding onto these experiences is a little like leaving home. It is hard to decide exactly how the goodbye should feel. Frightening to grasp how much more I’ll need to grow? Exhilarating to begin the next step? Sometimes I catch myself counting pieces of knowledge I’ve amassed as if to assure myself I’ve learned enough. Given the vastness of medical knowledge, it’s an absurd exercise because the beauty of medicine lies in a physician’s on-going need to learn. In speaking with my co-residents, this is what emerges as the most rewarding part of graduating: understanding that the best we have to offer patients isn’t only information but our ability to listen and change. For that, we are ready.

Anne Toledo is a family physician.

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