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Fourth Year: Fences

The last year of medical school heralds more than just the end of an era. It brings with it the confidence in a career choice doubted several times just a year ago. When you’re a fourth year you begin to feel the warmth of the light at the end of the tunnel. You magically know the answers to questions thrown like daggers on the wards. You’re not constantly wondering if you’re standing in the right place or saying the right things. You feel like a useful part of the team and patients just might mistake you for their doctors.  It makes you feel, if only for a few moments, that you can actually be someone’s doctor in just a few short months.

Fourth year also offers a considerable amount of free time. Rotations are a lot more relaxed since you’re not worried about going home to do a bunch of UWorld questions. Instead, your focus shifts elsewhere. The first two years of medical school are dedicated to the details of disease pathology. Third year than becomes about seeing real patients manifest these pathologic states. Fourth year then becomes about taking a step back, seeing a patient beyond their disease and learning all the finer skills.

When I was on my medicine rotation, one of my earlier rotations of third year, my senior resident did a great job teaching the basics of clinical care – how to perfect our histories and physicals and how to make a note perfectly nuanced yet brief. But, at the time, I didn’t realize how wonderful he was at communicating with patients. We worked at a large safety-net hospital where some patients, unfortunately, could not prioritize their health care since their housing and food needs were often unmet. However, our resident always managed to see eye-to-eye with every single patient on our list. He calmed down a 50-year-old woman with unstable angina who needed further cardiac workup but was bent on leaving against medical advice to take care of her grandchildren at home. We had another challenging patient, frequently hospitalized with pulmonary sarcoidosis, who was never content with any plan the medical team came up with. My resident could concoct a plan of action that even she approved of. Looking back, I wish I had focused more on how my resident was able to have these conversations with his patients. I remember how he conveyed genuine empathy and always gave his undivided attention when listening to patients. He never went into any room with an agenda but always managed to act in the best medical interest of the patient.

As a patient myself, I always noticed the small things that my doctors did. There were those who would ask if I had any questions as they hovered near the exit with fingertips flitting around the door handle. And others who would sit firmly at the edge of my bed whenever they talked to me and remember to turn the lights off and cover me up after examining me at four in the morning. These little actions led to trust. I was more likely to believe that they had my best interests at heart when they showed small signs of consideration. I thought back to my medicine resident and it made sense why his patients felt heard and cared for. So much of our communication is nonverbal – and kind gestures go a long way in a stressful hospital setting.

I found myself empathizing with my patients and really putting myself in their shoes. I always thought it was valuable to form strong bonds with patients and their families, especially if you practice in a specialty that lends itself to long-term relationships with patients, which is why I was surprised by one of my residency questions. How would I learn to establish boundaries with my patients and when would I decide to draw a line with them?

My interviewer was an experienced pediatric oncologist who routinely maneuvered difficult ethical situations with his patients and their families. We launched into a conversation about the unique position doctors occupy. They see their patients through demanding circumstances for extended periods of time and, as a result, become very integrated into their lives. You need to know whether you will be the kind of doctor who will go to your patients’ birthday parties and funerals, he said.

Before I could reply, my interviewer went on to say that, for him, it wasn’t possible to be a part of his patients’ lives outside the hospital. He knew his limits and was able to established boundaries for himself so it wouldn’t affect his ability to care for his patients. He encouraged me to pay attention to these subtleties as I embarked on the rest of my journey.

I left that interview feeling like I still had much to learn. A little more confidence in the hospital didn’t necessarily ease the process of making difficult decisions like my extent of involvement with patients and their families. I started to wonder how to cultivate those principles and begin to set boundaries for myself. I realized that by paying attention to memorable interactions between patients and physicians early on in your medical career, you start to build a repertoire of finer communication skills. As I finish up the last few months of my fourth year, I look forward to conversations with various physicians to see whether they would choose to go to birthdays and funerals, knowing that in the end it’s going to be something I have to figure out on the way.

Sarayu Kumar (3 Posts)


Emory University School of Medicine

Sarayu is a fourth year medical student at Emory University School of Medicine. She double majored in Chemistry and Environmental Sciences and minored in Creative Writing at the University of North Carolina at Chapel Hill. When she's not doing med school related things, she loves exploring the food, music and comedy scenes of Atlanta.