Two years have passed faster than I'd like to admit. Long nights and thirty-hour call days have added up to two-thirds of my formal training. Frighteningly, in one more year, I'll be the attending physician, supervising residents' care of patients and making my own decisions regarding patient care with no oversight. The buck will stop with me, and I must admit that this looming fact is humbling and more than a little terrifying.

As I enter my last year of training, my responsibility is accumulating. Interns and junior residents have already started asking my opinion, as if I might be able to lend some salient idea about the work-up of their patient. Little does anyone know that it's all I can do to keep my own patients organized and moving through their visit to the emergency department. How I'll cover the other 22 beds in a busy emergency department is beyond my comprehension. Lecture scheduling, monitoring conference attendance, and negotiating resident conflicts and complaints will be added to my clinical responsibilities next year. I have the support and encouragement of my attending physicians who assure me that I'll be prepared for my increasing duties.

Here's the rub. I'll start applying for positions in the next couple of months. I'll have to set aside my own insecurities in order to present the confident, competent emergency medicine physician that people want to hire to their group. No one wants to hire the wet noodle that I all too often feel like when faced with the difficult diagnostic and procedural challenges presented in emergency medicine. Yet most senior emergency medicine residents have signed contracts for July of the year of their graduation far before December of the preceding year. Here's to faking it! I'll put a new suit on, smile and nod.

The 45-year-old nonsmoker, healthy marathon runner with reproducible chest pain and no family medical history of heart disease arrives. Do I admit for further cardiac work-up? Do I consider pulmonary embolism? I ask my attending his or her opinion, relying on them for the final say. A 23-year-old female reports with 2 days of abdominal pain and the usual work-up fails to reveal a diagnosis. Do I order the CAT scan or pelvic ultrasound? Do I admit for observation or give return instructions? These are the questions I find myself asking myself. These are the dilemmas I can lean upon my bosses' years of expertise, but soon someone will expect me to know the answer or be able to perform the intubation on the difficult trauma patient. Most people have bad dreams consisting of crazed men with chainsaws. I have nightmares about establishing intravenous access on my own without an attending or in-house surgeon to rely upon.

I'm always far too hard on myself, I realize. It's been practical for me throughout my career. Perfectionism has allowed me to achieve as an undergrad, be accepted to medical school and graduate, and to enter a competitive emergency medicine field. So it's hard to abandon old habits as I mature in my career. It's hard for me to allow myself the room and time to let myself learn. No professional career is established immediately, but the nature of medicine demands perfection from the beginning.

The truth is my wisest attending physicians claim it takes five years of practice to "get good" at what we do, and a full ten years to master the art of emergency medicine. This certainly doesn't mean we fail or hurt patients, but the subtleties of practice develop as you learn to intuitively size-up a patient's condition in a flash, much in the way Malcolm Gladwell describes in his bestseller Blink. He described a phenomenon called "thin-slicing" that describes the instinctual process doctors, firemen, police officers, art critics and other professionals use to evaluate a situation in a glance as they develop their professional expertise. So, I'll try to cut myself a break for once and try to remember that no matter how much I want to believe I'm unique, every one of my colleagues feels the exact same way or has in the past. I'll rely on the training and repetition of the skills and concepts I've been establishing over the past few years to carry me through the fears of actually having the job I've wanted since I was seventeen, sitting in a stuffy classroom, daydreaming during math class.

Andrew Jacques ('05)