Before this year, I had never truly experienced imposter syndrome.
I knew what it was, of course. The feeling of being out of one’s depths, not belonging, drowning under one’s own expectations. At various stages in medical school, even in my first years of residency, we had been counseled about it — you are not alone, they would say. I would smile and nod, and wonder to myself why I wasn’t feeling the same soul-crushing solitude that everyone else was.
It sounds arrogant, but I don’t mean it to. I had always had a good understanding of my own abilities and shortcomings (which I attribute to my analytic reading skills and the near-constant self-reflection that I subject myself to) — I had the self-awareness to know where my limits were.
But last week, I finally felt it. And it didn’t come the way I expected it to.
In surgical training, as in all education, we expect things to progress in a certain order. We have level-specific expectations: the performance of an intern in July will be very different from what we’d expect later in April; a PGY2 should know more, and be able to do more, than a PGY1.
My first week back after my two-year research hiatus, I found myself in the trauma bay with a man who had fallen off his motorcycle and avulsed the skin off his arm. Luckily for him, he had no fractures, or damage to major structures, so I would place a few stitches and he would be on his way. Well, actually — the medical student, who had eagerly jumped to attention when the attending and I discussed the plan, would place a few stitches (such was my intention).
I began to show him how to place the sutures, explaining how deep and far apart each suture should be.
“I’m going to instrument tie,” I told him, “because we only have a few sutures and the length isn’t very long. But you should hand tie.”
“I don’t know how to hand tie,” he said.
I paused, looking up at him. For a moment, I was baffled — somewhat in shock that a student who didn’t know how to tie knots had asked to independently close a laceration.
“They only taught us instrument ties at school. Are hand ties better?” he continued.
“It’s not that one is better than the other…” I began, not sure how to approach this question.
I watched him struggle to hold the needle driver, the instrument thrown open wildly, flailing about as he attempted to regrasp it. He jabbed at the patient’s flesh, pushing roughly into successive layers of tissue until finally, he succeeded at bringing the needle point out below the skin.
I held my tongue. I’d given the patient some local anesthesia, so he couldn’t feel anything — but he could hear us.
“Alright,” I said as he grabbed his unprotected needle, unsure of how to reload it onto the needle driver, “I’m going to do the rest.”
I took no pleasure in confiscating the instruments from him.
“You need some more practice before you’re ready to suture on a patient,” I said to him quietly. “You have to learn how to tie a knot before you can close a laceration.”
You can’t run before you walk, I thought to myself.
Why do we insist on doing things in a certain order? Why must A come before B?
During my first year of college, I prepared to take Calculus 1A and 1B — both requirements for my major. I could have skipped out of 1A, thanks to my high school classes, but at the time, I thought it would be better to take both, to ensure I had a good understanding of the basics before moving on to more advanced concepts.
I had the right idea, but my plan backfired. In math 1A, we covered introductory concepts that my high school math class had skipped over entirely. And so try as I might, I could not learn in reverse order; it made no sense to me.
In my second semester, I got to math 1B — a more advanced calculus class. Miraculously, things began to make sense; the concepts were more closely aligned with what I had learned in high school, and my efforts to understand the material actually paid off. I understood, then, why learning must occur in a specific order; because unless that order is followed, it is very difficult to backtrack, to understand anything else.
Now that I am back in residency as a PGY3, where does that leave me? I learned how to walk, yes — but then I didn’t use my legs for two years. And now that I’m back in the hospital, I’m expected to run — but because of my lack of practice, I am functioning somewhere in between a walk and a run: an odd, off-kilter, stumbling kind of canter.
A few weeks ago, I lost my interns. Not ‘lost’ in the scary, hospital use of the term — I mean that literally, I could not find them. It had been a long week of incorrect and incomplete presentations on morning rounds, misunderstood instructions, and unnecessary arguments, and my stress levels were reaching a new high.
What wasn’t I doing? Why was I failing them?
My whole life — or at the very least, throughout my medical career — I have prided myself as being a good educator (or at the very least, as someone who cares about education). So to find that my team was missing, that they were ill prepared throughout the day, that it had been over a month of their intern year and they still could not adequately present a patient on morning rounds — perhaps I wasn’t the educator I thought I was. Perhaps, I mused, even more concerningly, I didn’t have it in me to be a good leader.
Maybe it is as simple as going back to the basics: A before B. Become a good physician before you try to be a good leader.
But what happens when there are no instructions on how to get from A to B?
It is easy to learn to suture, to call a consult, to follow instructions. But earning respect, achieving that precarious balance between having high expectations and allowing for mistakes — these are difficult tasks. There is no clear path towards them; they exist as nebulous things that, for now, I can only wish myself into.