Residency is very different from medical school.

(Thanks, Captain Obvious.)

I had a flashback this week to our "orientation to the clinical years" just before beginning my third year of medical school. I remember the out-going third year trying to coach us on various things - like writing a good note, making a good presentation, etc. I remember asking "So, what does do you do as a third year?" He gave some answer involving "helping with floor work, updating the list, faxing for records, following up on labs, ad infinum", and I remember thinking by the end of is "Yeah... but what do you DO?". I ahd not tangible mental image of what my days would be like. As I discovered over the next few weeks, you can't really understand it until you have to do it.

I think the same goes for residency. Sure, you have a lot of interaction with residents as a student and you get a sense of their responsibilities and how a resident's day is structured. But you don't really understand until you have to do it. A few of the key differences I've found include:
1) There's way more things competing for your time than you have as a student. At any given time, this includes: managing patients on the floor, discharges, seeing patients in clinic, logging procedures, prepping for conferences or tumor board, teaching time, self-guided reading time, prepping for OR cases, didactics, preparing a presentation, practicing basic surgical skills, graded laparoscopic assignments, and maybe a research project or two. As a student, you also had some of these requirements, but if you skimped a bit someone may or may not notice, and no harm no foul. As a resident, if you don't do them, they don't get done, and someone always notices.

2) As a student, you try to know everything about your patients. As a resident, you need to know everything about your patients. There's redundancy in teams to help mitigate this, but there's always the possibility that you may be the only person to follow-up on a lab or check a vital during the day. And that may end up being critical to the patient. It requires a great deal of focus throughout the day to remember to follow-up on things when there's a myriad of other issues continually competing for your focus and attempting to distract you.

3) As a student, you study a lot, but your primary motivation is often your grade. Sure, you convince yourself to read sometimes because "you need to know this for the future" but that often becomes much less of a motivator than impressing those that will evaluate you or an upcoming shelf exam. You also jump around every month, so you reading often will be a sample platter rather than a 4 course meal. As a resident, you read because you need to know the information. Not just because its expected of you, but for the good of your patients. Reading is more intensive on given topics and can feel more exhausting - I feel like I need to hang on to everything that passes in front of me because it is all important, and I feel like there's so much to learn and retain and I want to tackle it all at once.

4) Your skills explode by sheer repetition. As a student, you develop certain skillsets, but the next month you're on to a new discipline and most things you learned pertinent to a specific field fade away. As a resident, the skills you need to learn how to do are the things you are doing every day, and you do them over and over again.

5) The attendings really do rely on you. There was talk at my medical school that a good student is always "value added" on a service. As a resident, you are "value needed."

I think it all comes down to a switch in the manner of your responsibility. As a student, you try to take on as much responsibility as possible. But a lot of it is faux-responsibility (both for medicolegal and practical reasons). As a resident, you continually accrue more and more responsibility over the care of your patient.

I was in clinic the other day with a pleasant patient. I went through a lot of the things I had practiced in medical school - took a history, did a physical exam, developed a plan, went and presented the patient to the attending. The attending came and whirled through the room, checked a few things, talked to the patient about surgery, then left me with the patient to consent them for the procedure.

As I shook his hand as he walked out the door he asked, genuinely: "So are you going to be doing my surgery?"

I think that encapsulates the big switch that occurs in residency. You turn from purely a student into a provider of care. Over the coming years, I will read about the patient's condition, I will learn how to do his surgery, I will learn how to manage patients like him post-operatively. And I will do it not just to provide care, but the best care possible for that patient. Residency is about living that mantra.