Goodbye to All That: A Letter to My M1 Self

The cosmologist Stephen Hawking once said that we are all time travelers, speeding through the fourth dimension into the future. But we also have the ability, in a way, to travel to the past. By telling our stories we relive what happened to us and help give meaning to our present.

When first entering medical school I was asked to write a letter to my future physician self, expressing my hopes and desires for the physician I would become one day. While the actual letter is gone I remember the gist of what it said: be humble, take good care of your patients, keep learning, have a life outside of medicine, and have fun doing all of the above. Now, as a pulmonary and critical care fellow on the verge of transitioning to a faculty position, I have been looking back on the past 10 years of training. In particular, my mind has been lingering on those first moments of my medical career, a time that felt ripe with possibilities and hope, yet also full of anxiety and uncertainty about what the future held. Some things turned out as I had planned; others did not. Not being able to actually communicate with my M1 self, I imagined what I would say to him, and decided to write this letter.

Avi, do you remember the episode of The Office when Jim sends Dwight faxes from Future Dwight? Don't be alarmed, but I am writing to you on November 27, 2018, which makes me Future Avi. Ten years have passed since I was you but I remember how anxious and eager you felt—that twitchy sensation in your gut when you think about what might lie in store for your life and career, or the sense of deep satisfaction and purpose when you wore your white coat for the first time. I also remember that letter you wrote to, well, me, when medical school first started, about the physician you hoped to become and the type of life you hoped to lead. Ten years have passed since you wrote that letter, and as I am about to finally finish medical training, I wanted to write back.

In medical school, be prepared to feel intimidated by your classmates when your first preclinical courses begin; you will experience impostor syndrome when you realize how intelligent and talented everyone is. Remember that although you are not the smartest person in the room—not even close—you belong in that seat and got there for a reason. Plus, a pass-fail grading system doesn't hurt. Along the way you will realize that your fellow students do incredible things outside of traditional medical practice—invent devices, launch startups, supply mosquito nets in African malaria zones, write Hollywood scripts, join the military. Treasure your time with them.

Nothing can prepare you for your first day on a clinical ward, which in your case will be in an operating room on a surgical service. You will fumble with the sutures (the plastic models feel nothing like real skin) and be stumped by many of the surgeon's questions, but spend most of the operation marveling at the sight of the inside of a living human body. The question, “how could this ever become routine?” will cycle through your head, as will the realization of how brave and audacious one must be to stick sharp objects deep into human beings, even if in an attempt to heal.

As third year progresses you will come to find a home in internal medicine, in particular the medical intensive care unit, where the dizzying combination of profound illness, heroic medical support, diagnostic dilemmas, and the need to ensure comfort for the critically ill and their families will crystalize as the place you want to work.

When you arrive at residency, though, you will realize that the next several years will be more difficult than you can possibly imagine. Getting through your day as an intern will require completing a monstrous amount of paperwork. On some of the busiest days you will have to choose between eating and using the bathroom. The ring and buzz of your pager will induce palpitations. Soon a vague feeling of global incompetence will arise. You will find yourself looking over your shoulder wondering who will cosign your orders, fumbling through your first central lines and paracenteses, and require course correction by seemingly all-knowing supervising residents. The feeling will fade to the background, but never completely go away, as years pass and you grow in competence. Many of your patients' lives will be derailed by substance abuse, trauma, and mental illness, and it will seem like you can't help them. You will have to discharge homeless men and women to the street with a bag of prescriptions and maps to city shelters.

You will see death often, and think of Dylan Thomas raging against the dying of the light while de-gloving after unsuccessful cardiopulmonary resuscitations. You will stand at the bedside, priest-like, and declare that patients have died but feel a sense of intrusion into their family's grief. They will thank you again and again for trying, but you will never feel like you belong there.

You will be home and see your family less often than you expected. Realize that if your resident offers to send you home early then you should accept immediately and without question.

The next several years will also be more special and gratifying than you can possibly imagine. You will diagnose “zebras.” You will literally save lives too many times to count. You won't recall many names or faces, but you will remember the stories. You will help people navigate some of their most difficult moments, offering hope and comfort. Patients will introduce you to their loved ones as their physician and the feeling of honor and privilege will not diminish.

You will enroll in a pulmonary and critical care fellowship and discover a passion for caring for patients with asthma. You will dabble in biomedical research but will find a home in medical education. You will make loan payments, invest, and save for retirement. You will see Giverny, Michelangelo's David, and the ceilings of the Sistine Chapel and Sagrada Familia. Soon you will meet and marry an amazing woman and have a beautiful son. They will bring you more joy than anything else in your life.

One day you will find your father's dusty doctor bag, exactly as it was before he died, and read the journal article he must have annotated in his final days. His reflex hammer will sit in your white coat pocket as you walk through hospital hallways in the early morning hours, sunrise sneaking through tall windows in the distance, hoping he would be proud of the person and physician you have become.