From intern to resident

I took this photo at the end of a night shift in early April 2020. From the seventh floor I could see the long line of socially-distanced hospital staff waiting in line for pre-work infection screening.

As of a few days ago, I am officially a second-year psychiatry resident, or PGY-2 (see end of post for a quick primer on the quirks of residency year naming). When I began my intern year in June 2019 I was excited to practice medicine, but was also apprehensive about whether I would find the work fulfilling, or whether I would experience burnout.  Both turned out to be true: it was an incredible year wherein I’ve truly enjoyed [finally] getting to be a doctor, and I’ve also learned invaluable and sometimes unexpected lessons that include how to choose and adjust antipsychotic doses, but also how to more accurately recognize and then mitigate burnout.  I’ve had the enormous privilege of learning from patients, fellow interns, senior residents, attendings, nurses, technicians, social workers, nutritionists, psychologists, and occupational therapists at the VA, at San Francisco General, and at Benioff Children’s Hospital; in different specialties (psychiatry, medicine, neurology, pediatric neurology, and adolescent medicine); and in a variety of different clinical settings.

At the start of residency I had hoped, but certainly hadn’t expected, that my fellow residents might become close friends.  My fear that I would be terribly unsuccessful in making new friends turned out to be unfounded; in fact, some of the senior residents have described our residency class as notably cohesive, which bodes well for the coming years.  Our camaraderie certainly helped when, two thirds of the way through the year, we unexpectedly faced the specific challenge of working in healthcare during a pandemic with various unknowns.  From February through June I worked on the same psychiatric units at the General, and it was at turns fascinating, stressful, and educational to watch the city, our institution, and our department adapt to this public health crisis.  Amid bouts of uncertainty over whether the curve would be flattened or if we would end up with a terrible outbreak on our units (which, thankfully, did not happen), the overall consistency of my schedule during these past months gave my life structure.  Together with my colleagues I settled into the new normal of daily pre-work screening questionnaires and surgical masks all day.

Then, toward the end of the year, we all found ourselves grappling with the role of structural racism and police brutality in our communities and our medical fields, and the impacts (both acute and chronic) on our patients, colleagues, and friends.   As part of this long-overdue collective reckoning, we have had to rethink what it means to be supportive of each other, to hold each other accountable as allies, and to advocate for each other and for the patients we serve.

During orientation for the incoming interns, a classmate and I each shared a couple sentences about our cultural backgrounds and how they affected the start of our residency.  I shared that I am a Chinese-American immigrant who grew up in a relatively liberal and well-educated college town, and that while during medical school I was involved in some equity-focused advocacy efforts, it was during intern year that I finally began unpacking my intersectionality and privilege in earnest.  I believe a necessary step in becoming an anti-racist physician is understanding one’s own cultural intersectionality, that we are each at a different stage in this process, and that wherever we are is a fine place to start.  Just as this chosen career path requires that we hold space for our patients’ emotions and inner conflicts, so too do we need to hold space for our own uncomfortable truths.  And so, I am reading, listening, writing, and thinking.  

My second residency year (PGY-2, or post-graduate-year 2) will start next week with three months on consultation-liaison psychiatry at UCSF, followed by three months on adult inpatient psychiatry at UCSF, and then six months of outpatient psychiatry at the VA.  Throughout the year we take call shifts at the General, VA, and UCSF.  Each residency year brings new expectations and challenges, and just as I did a year ago, I again find myself feeling both apprehensive and excited.

***Summary of residency year naming schemes: each year, or title for a resident in that year, is often named as “Post-Graduate Year” followed by the number: PGY-1, PGY-2, etc. Another informal shorthand for residency years or residents is R1, R2. Thus, a second-year resident could be referred to as “a PGY-2” or “an R2,” and is in their PGY-2 or R2 year. The first year of residency (PGY-1) is colloquially called “intern year” because some medical specialties, such as radiology or neurology, require that their residents first complete a general medical internship (which may or may not be at the same institution) before starting specialty training in PGY-2. Psychiatry residency is one that begins in the PGY-1 year. Regardless of these differences, across specialties, the completion of the PGY-1 year is thought of as the transition from internship to residency.

Looking back: Scrubbing in and suiting up

This was a short piece I originally posted on my old blog in May 2018, when I was a third year medical student halfway through my 12-week surgery rotation. On re-reading it now, this piece transports me back to a time when I had already decided to pursue psychiatry, but was also acutely aware that this surgical rotation was the only one I would have. As such, it represented a brief but memorable immersion into a dramatically different arena of medicine.

There is a unique desperation that arises during the medical student surgery clerkship, when the student is confronted with ostensibly simple tasks – such as finding a roll of paper tape, or opening the correct dimension of gauze, or holding a retractor with the right amount of tension – that have suddenly become staggeringly challenging.  Great attention must be paid to the placement of one’s hands when one is doing nothing but standing and observing.  The differentiation between what is light blue (the color of sterility and safety) and not light blue is now the most salient, if one wants to avoid the justified wrath of the scrub technician, to say nothing of keeping alive the chance that one will get asked to hold an instrument or possibly even, if lucky, help close an incision. 

It is safest to keep one’s arms crossed, or forearms folded over one’s stomach, or, ideally, resting on a draped area that is away from the operating field, if the surgeons or a particularly thoughtful scrub tech invite one to step closer.  It is definitely not safe to begin to doze off while sitting on a stool between a patient’s [draped] legs, while watching the surgical proceedings on the screens around the room, to then realize that one has just contaminated one’s gloves by touching the stool.  This may or may not have happened to me in my second week on the inpatient gynecology service, during a six-hour surgery, during part of which I had been told to push in various directions and then isometrically hold an instrument placed in the uterus, while the surgeons used the Da Vinci robot to manipulate parts of the pelvic organs through the abdominal wall.  One of the more surreal moments in my life: being told “Harder!  Push to the right!  No, the patient’s right!,” contorting my shoulder into increasingly uncomfortable angles, seeing on screen the uterus move with my clumsy adjustments, while the surgeons stared into their arcade-like consoles and used carefully calibrated movements of the control knobs to trigger precise adjustments of the articulated robot arms.  For obvious reasons I was extremely alert during that part of the surgery, but all bets were off once my physical and intellectual involvement was over and I was left to watch.

It took well over a week – and if I’m being honest, closer to two weeks – before I felt comfortable scrubbing in, and then just to be a minimally invasive component of the OR milieu.  By the fourth or fifth week, I started appreciating the rhythm and routine around me.  The structure-seeking part of me did find comfort in the repeated ritual of being gowned and gloved by the scrub technician:

After scrubbing for upwards of three minutes, walk into the OR with hands held up in front of you, elbows away from your chest, water dripping downward onto the floor.  Take a sterile towel and, still keeping your elbows up, dry the hands and forearms on one side, then use the other (clean) side to dry the other arm.  Place your arms into the gown which has been held open for you, extending your arms under the arms of the scrub tech with only a slight back bend, and immediately straighten with your hands once again held in front of you, fingers together, so that the arms of the gown can be pulled down just enough.  When the first glove is held open for you, slide one hand down into it, then use those now-sterile fingers to help hold open the second glove that is proffered.  The back of your gown has already been closed by the circulating nurse, but you now ask him or someone else to take the paper card tethering your waist ties, then spin counter-clockwise and pull the other waist tie off with a subtle flourish, so that you can fully close your gown.  You are now enclosed in cleanliness, and you have only to avoid messing it up.  

This sequence of actions, repeated at the start of every surgery, armors the surgeons – and wide-eyed medical students – in a papery, synthetic, fluid-proof, and anonymity-granting suit.  When everyone who has scrubbed is gathered around the draped patient, with only the operating field exposed, they coalesce into a nucleus around which the outside world, the non-sterile and chaotic and hazardous, recede.  Despite interruptions by pages or phone calls, or episodes of chatter regarding weekend plans or how the family is doing, there are always stretches of collective scrutiny on the task at hand.  Sometimes it seems to me that in the OR, the patient’s personhood and humanity are intentionally deemphasized, tucked into the background by the blue drapes.  And yet I also see that in the OR there is a unique dimension of respect for the human body and its natural variations in anatomy and [patho-]physiology, which create the potential for surgical challenges that are not always forseen by imaging studies.  I sensed that the haptic unpredictability of surgery, as well as the monastic focus that must result, is part of what surgeons love about their work.  As an observer and intermittent participant, scrubbing in provides a memorable glimpse into this unique cognitive realm.

Looking back: Grad school lessons on how gender matters

This was the second in a pair of posts from early 2015, when I was a PhD student in Neuroscience. Now that I am working in a medical specialty that is quite balanced in terms of gender, the disparities that were so apparent in my graduate training are less present in my day-to-day clinical work. However, within academia, the same discrimination is present and relevant, to say nothing of even more pervasive and toxic structural injustices toward BIPOC individuals.

Lesson: Gender matters sometimes, even for grad students in a generally supportive environment.

A professor once gave my class some excellent advice on scientific presentation.  He said that every time one gets up to speak in front of colleagues, even in a casual setting like a lab meeting or small seminar, one should be as well-prepared and professional as would be expected for a job talk.  His point was that each presentation reflects on the speaker’s reputation as a scientist and scholar, and I try to keep this in mind.

Some months after hearing this advice, it also occurred to me that if a woman happens to be working in a field that is skewed toward men, her gender might already be a more salient factor as soon as she steps to the front of a room to speak.  A scientist’s presentation skills, confidence level, and quality of work are obviously important regardless of gender, but these metrics might be evaluated more stringently for a female scientist giving a talk (even on a subconscious level, because I believe that most scientists are not consciously sexist).  Furthermore, what is assumed about her overall competence as a result of these metrics might have a greater impact on her career than if she were a man.  In a male-dominated field, a female speaker’s public presentation could even impact what others assume more generally about Women In This Field.

I don’t intend for this post to be a manifesto, but I do think what I just said deserves some consideration of the broader context.  There is plenty of evidence demonstrating that perceptions of competence can differ based solely on gender.  To cite some primary sources, one study in which subjects performed a contrast sensitivity test showed that men and women are held to different standards of competence (Foschi, Social Psychology Quarterly, Sep 1996).  There was also that memorable 2012 PNAS paper highlighting how, when faced with two hypothetical applicants with identical profiles except for name (Jennifer or John), science faculty members of both genders were more likely to offer John a laboratory manager position, and with a higher salary than would be offered to Jennifer (Moss-Racusin et al., PNAS, Aug 2012).

In 2014, another PNAS paper confirmed and enhanced the 2012 findings by showing that in choosing a candidate for an “arithmetic task” based solely on the candidates’ physical appearances, employers of both genders were twice as likely to choose a male candidate (Reuben et al., PNAS, Jan 2014).  The degree of individual bias correlated with the Implicit Association Test (IAT) score, which in this study measured the degree to which the subject associated an individual’s sex with his/her science-related ability.  Even after receiving objective information about the candidates’ actual performance on the task, “suboptimal hiring decisions” (i.e. hiring the candidate with lower performance) tended to favor a lower-performing man over a higher-performing woman.

A meta-analysis published earlier this month concluded that overall “women may be more likely to face discrimination in male-dominated environments, whereas, on average, neither gender has an advantage in female-dominated or integrated environments” (Koch, D’Mello, and Sackett, Journal of Applied Psychology, Jan 2015).  Encouragingly, these authors also found that gender-role congruity bias (i.e. preferential selection of men for male-dominated jobs) is reduced when the applicants are shown to be highly competent, when the decision-makers are “motivated to make careful decisions,” or when the decision-makers are “experienced” with “organizational decision-making” and are not simply pulled from, say, the frequent psychology study population of undergraduates.

Now, I am fortunate to be in a gender-balanced lab and relatively gender-balanced training program on a campus that is enormously collegial.  I have mentors and instructors of both genders who actively promote the advancement of women in science.  I also emphasize that I have not, as far as I am aware, experienced any instances of overt gender-based discrimination that have affected my educational opportunities.  That said, I am also a trainee in a subfield of neuroscience – imaging and analysis of cortical network activity – that is male-dominated, which probably has some association with the topic’s heavy emphasis on technology development, hardware, and computational techniques.  I love and believe in my project, and there is no other scientific topic in which I’d rather train. However, my intellectual excitement for my research doesn’t blind me to the reality that my field is still gendered.  I certainly have experienced, witnessed, and heard about episodes of subtle or inadvertent sexism, which can still be impactful.

As part of this reality, I’ve had to learn that men and women often assert themselves and/or respond to negative interactions in very different ways.  At one point, I sought out the advice of a female mentor because I was having difficulty navigating a particular research-related situation.  The situation involved some interpersonal dynamics that I thought might have something to do with gender, but didn’t necessarily want to label as such.  The mentor practically read my mind and told me that in this circumstance I should in fact “act more like a man,” i.e. be more aggressive in advocating for my point of view.  It was slightly jarring to hear a female faculty member so matter-of-factly confirm the gender differences I had suspected, but her attitude was also reassuring, and her advice certainly proved effective.

About three months later, another faculty member and I unexpectedly started discussing the issue of gender differences in science, and in particular how men and women respond to negative interactions in the workplace.  This faculty member pointed out that many men tend to “call B.S.” readily and then promptly move on, without giving it much more thought, whereas women – irrespective of competence, confidence, or ability to be aggressive – sometimes tend to ruminate about what happened.  This struck me as being an uncanny reflection of how I responded to unexpectedly negative interactions or inappropriate comments: briefly freezing with surprise, trying to exit the interaction in an uneventful and often non-confrontational way, and then obsessing afterward about all the things I should have said in the moment.

Goals: To be a more assertive or aggressive self-advocate, when constructive; to recognize when a situation is “B.S.” and point out when it is problematic or inappropriate; and to let go of negative interactions afterward instead of ruminating about them.

The aforementioned conversations echo other discussions I’ve heard on “The Broad Experience” by Ashley Milne-Tyte, a podcast I highly recommend.  One particular episodefocused on gender differences in workplace communication and quoted Barbara Annis, an expert on gender intelligence: “So women tend to worry more.  And as I mentioned, ruminate more, that internal dialogue that goes on. And I always say to women, think about this, is there any cheese down that tunnel [i.e. a real problem], first of all, to worry about this?  Or is it time to, you know, say OK, I’ve handled it to the degree that I can, and now I’m going to let it go. [….] Now there are some things that it’s really important to worry about, so I’m not saying dismiss on things that are really vital.  But the small things, if they are on your worry list I would strike them off and create a clean slate.”

Having some lactose intolerance myself, I find the cheese analogy particularly resonant.

Looking back: Grad school lessons about confidence

I originally wrote this piece in January 2015, when I was a second-year PhD student in Neuroscience. The same lessons still ring true now that I am in residency, including: “I am trying to redefine my conception of competence to include the effort I expend and the progress I make, and to hold more confidence as a result.”

Now that I’m halfway through my second year as a PhD student, and recently submitted a fellowship application describing My Thesis Project and My Intended Scientific Training, I’ve been reflecting on the first 1.5 years of grad school and making a list of What I’ve Learned So Far (and/or Am Still Learning).  Some of the items on my list were unsurprising, such as:

1) Developing some broad understanding of neuroscience and a more in-depth understanding of my narrower research field;
2) Two-photon imaging (which, by the way, is awesome), some MATLAB programming, and various other experiment-related techniques;
3) How to read papers more efficiently and critically;
4) Grant-writing;
5) Presentation and teaching skills;
6) The importance of strong mentorship;
6) The necessity of unwavering support from family and friends, plus lots of tea and dessert (and some wine).

But as generally happens in life, several other lessons were unforeseen, and gave rise to new personal goals.  I thought I’d write about them as a series of blog posts, this being the first.

Lesson: The power of confidence is very real.  

In my years before grad school, it repeatedly struck me that because I tended to be comfortable speaking in group settings (in med school, those were typically the Problem-Based Learning or Doctoring groups), I was frequently perceived as being a highly competent student.  In reality, my comfort level with participation in discussions or with public speaking didn’t necessarily reflect my mastery of lecture material.  Even so, it was clear to me how an appearance of confidence could create an assumption of competence.

During both college and med school, measures of progress and achievement are frequent and often externally defined in the form of exams, essays, or short-term projects (such as preparing a piece of music for performance).  But in grad school, competence is less concretely defined on short time scales.  There are classes, sure, and having a knowledge base in neuroscience is clearly important for becoming a neuroscientist, but successful completion of classes isn’t remotely sufficient to make a good scientist.  Instead, scientific competence has much more to do with creativity and innovation, ability to understand the literature and also see beyond it, ability to design and re-design experiments, project management and trouble-shooting skills, ability to work well with colleagues and advisors, and a whole lot of perseverance.  In theory, one develops and/or solidifies these attributes over the course of a PhD and then further develops toward being an “independent investigator” during a post-doctoral fellowship.

It turns out that although these metrics of competence may be very different from the metrics before grad school, the connection between outward confidence and perceived competence – and the potential disconnect with actual competence – is just as strong.  If you asked me whether I am a competent scientist, my answer would be “Not yet, but I’m working on it.”  I am reasonably sure of my potential for becoming a productive and capable scientist, but I’m also near-constantly and sometimes painfully aware that I still have so much learning and growing before I get there.  My self-doubts about being very much “in training” can seep into what I project externally, and since confidence and self-advocacy often go hand in hand, my doubts could definitely affect not just how I am perceived, but also the opportunities that I seek or am offered.

Especially when it comes to rectifying a weakness or learning a skill that is very necessary for my research, such as MATLAB programming, I tend to feel insecure until I feel that I’ve achieved enough competence in that skill.  But how would I define “enough competence”?  In the past year I’ve had to recognize that I may never achieve the level of mastery that I would ideally possess for any given skill, that there will always be scientists who have years more experience and ability than I, and that my own benchmark of competence will constantly shift as my training progresses and my research pursuits evolve.  That the target is moving doesn’t mean that I’m not making solid progress, progress about which I should be confident, because my incremental progress will still enable me to produce solid science in my own right.  Thus, I am trying to redefine my conception of competence to include the effort I expend and the progress I make, and to hold more confidence as a result.

Goal: To develop greater confidence in my abilities and progress, while working hard to constantly improve my competence as a scientist.

P.S. Based on what I’ve heard from other grad students, this process of navigating our scientific and personal development is fraught with insecurities for everyone, whether we are outwardly assertive or not, and so I sense that this first goal is shared by many of my peers. 

There have also been some interesting media discussions related to this subject.  The specific topic of how confidence and competence relate to gender, and possibly to success, was explored in-depth in a fascinating and provocative article published in The Atlantic last May: “The Confidence Gap” by Katty Kay and Claire Shipman.  More on gender in a future post.