What you need to hear at your medical school graduation

Well done! Strong work! You’ve done it!

Four years (often more) of perspiration have earned you two extra letters (often more) in your name. You should be proud. Nothing should get between you and a gigantic glass of bubbly today. The world feels different. You feel different. But are you?

The thing about ceremonies that feature costumes, protocols and rituals is that they confer upon participants a sense of change. Just look at weddings — the two people who approach the altar are altered when they leave. Similarly, to borrow from Dr. Abraham Verghese, a patient gown, a white coat and a physical exam can transform two strangers into a doctor and a patient.

Between solemn recitations of the Hippocratic oath and congratulatory speeches, you might conclude that a magical metamorphosis has transpired. And while it is true that the years of medical training have changed you, there remains a vast canyon between your skills and knowledge as a fourth-year medical student and the doctor you have always wanted to be. Many overlook that chasm as their graduation gowns billow in free-flowing superlatives. I know I did.

Heady from graduation and a handful of institutional awards, I headed off to intern year with more confidence than caution. As a fourth-year student, I had won praise from kind attending physicians for managing four to five patients instead of the usual load of three. On my first day of inpatient wards, I received sign out on ten very sick individuals. Addled by the details, I took an eternity to pre-round and showed up late for rounds.

In medical school, I had received approbation for my thoughtful and, at times even, eloquent presentations by indulgent residents. But flooded with all these new patients, I mixed up patient stories, bungled vital signs and lab values and choked on simple questions about management. Good interns are supposed to have their orders placed, consults called and notes written by early afternoon. I wasn’t even close to done with my tasks when the evening team came to relieve us.

When nurses had questions, I frantically searched UpToDate for answers, ultimately turning to my residents and attendings for guidance. And when patients got emergently sick, I usually just got in the way. Far from healing patients, I usually felt that I was holding up their care. In fact, I felt like a child in a costume, playing “doctor.”

Hadn’t I been anointed as a doctor at graduation? Then why can’t I handle residency? Do I belong here? Am I a charlatan?

The discrepancy between the doctor I had imagined myself to be on graduation day and the doctor I actually was on day one of intern year was stark. The gap between expectation and reality dragged me into self-recrimination and depression. I had fallen into the chasm and there was darkness.

With time, I learned. We all did. Pre-rounding got easier. I learned to manage sick patients. My tasks were done before the evening signout. With introspection and a heavy dose of realism, my self-image and my reality merged into one. The guilt of being a charlatan also receded, but I don’t expect it’ll ever truly go away.

Every year, I see interns go through the same feelings of inadequacy and self-recrimination. While these feelings are powerful motivators for learning, they can also breed burnout, depression and even suicidal ideation.

And this is why I believe we need a modicum of restraint in the message we give out on graduation day. The truth is that medical school gives you some of the skills and knowledge for intern year, but it cannot fully prepare you for the intellectual, physical and emotional hardships of residency. The strength and the skill will assuredly come in time, but you should not expect to have it on day one.

Graduation from medical school is a rite of passage that invites you to become the doctor you want to become. The appellation of “doctor” is both a reward for the hard work you have done and a reminder of the even harder work that lies ahead.