On my first week of onboarding as an attending, before I had seen a single patient, I met the boulder in a training room.

It arrived as a screenshot. The EHR instructor clicked into a demo chart and a cascade opened: quality gaps, refill requests, preventive care nudges, “smart” routing rules that promised efficiency and smelled faintly of delegation without authority. I had imagined the threshold to attendinghood as a clean line: credentialing complete, badge activated, the cautious voice of residency replaced by a practiced calm. Instead, on the Friday before my first clinic, I realized what becoming a physician truly means: consenting to be answerable for work that, by design, will never be finished.

Orientation has its choreography: introductions, passwords, compliance modules, a tour that reduces a complex system to arrows on a floor plan. But somewhere between “Panel Management” and “Revenue Cycle,” the existential shape of the job snapped into focus. The clinic’s care-gap dashboard glowed with bright, corrective colors, an abstract art of deficit: mammograms, colon cancer screens, A1c checks, flu shots, depression follow-ups. Each square was a person, each reminder a tug on a sleeve. “Your panel will start small and grow rapidly,” someone said, meaning it as reassurance. I heard: The slope will steepen.

In residency, there was always a next rung to reach for, a senior or an attending whose authority could unstick the stuck. Now, even before my first patient has sat down, I can feel the quiet, administrative gravity of attendinghood. The gravity is not merely the inbox (though the simulation dinged with cheerful regularity); it is the recognition that medicine is less a series of discrete tasks than a commitment unfolding in time. Health does not stay completed. Grief does not expire by 5 p.m. Chronic illness does not remember your block schedule.

During a module on “inbox optimization,” a trainer showed us how to set up filters: STAT triage, refill batching, lab-result macros. The promise was that with the right templates, we can metabolize complexity into swifter clicks. I am grateful for craft; templates are a kind of mercy. But the deeper revelation was more austere: The boulder is not paperwork. The boulder is responsibility itself, our strange, chosen duty to keep showing up when the human condition refracts into alerts, denials, and aching knees. In that sense, the work feels close to what Albert Camus called the rhythm of the absurd, not futility for its own sake, but a lucid persistence in a world that does not tidy itself for our convenience.

In a lecture, I scribbled in the margin: Who pays the tax of time? We all do; unevenly. Patients pay in foregone relief; teams in churn; physicians in moral injury, the gap between what is right and what the structure allows. Becoming an attending means the bill arrives daily; my work is to turn some of that debt back into care.

There was also the tour of the human infrastructure, the part that keeps me from cynicism. I met the medical assistants who know which grandmothers bring candy for the front desk, the nurse who has a sixth sense for who is not answering the phone because they are working a double, the scheduler who understands that the bus route is the real social determinant today. I met the social worker who can, with two calls, make food appear in a kitchen by nightfall. Becoming a physician means I now sit at the center of this web, not to direct it as a soloist, but to keep it from fraying through attention and gratitude and the occasional stubborn insistence.

Because I have not yet seen my first patient, my resolve is still theoretical, which is risky. But clarity loves a deadline, and mine is tomorrow. So I am preparing, not to conquer the hill, but to choose where to meet it. I built my templates to begin with context (“What is new with your life?”), because the chart rarely volunteers it. I arranged my result notes to front-load harm: chest pain, suicidality, then the rest. I made a list of phrases that make repair easier when I err (“I caused confusion there; let me fix it”). I drafted a brief clinic policy for myself: never say “noncompliant” when what I mean is “outmatched by circumstances.” These are small tools, but they are the handles I will need on the boulder.

I am also letting go of the myth that mastery will abolish repetition. Residency trained my reasoning; attendinghood is already training my attention. The work will loop. The inbox will refill. The same questions will return in different mouths. My authority will be tested not by how rarely I need help, but by how quickly I seek it and how generously I share it. If there is a romance here, it is not in heroics but in stewardship, the unflashy promise to keep watch, to return calls, to remember birthdays, to write the letter that unlocks three months of stability.

Tomorrow I will open the door to the first patient of my panel. The boulder will be there, indifferent and steady. I do not need it to be lighter to be meaningful. I need to be faithful to the craft, animated by a team, and committed to the kind of revolt that Camus describes: a refusal to confuse absurdity with nihilism, paperwork with purpose. Medicine will ask more than I can give in a day. Becoming a physician means offering the day anyway, and then another, and learning how to place my hands so the push becomes, if not easier, then truer.

I write this plainly, protectively, and without ornament where it is not earned. Any clinical scenarios recalled from residency are composited and anonymized.

The hill awaits. So do I.

Sami Sinada is a family physician in Chicago. He examines how ethics and policy influence everyday clinical decisions and the systems that shape them. His work aims for clarity, conscience, and practical wisdom in primary care and medical education.