The patient is expecting you to say something. Remember to be professional but don’t be too formal. Keep it casual but avoid sounding inept. Should I have worn a nicer shirt? Check your voice—it’s a small room try not to be too loud. Your voice always gets really high-pitched, you’re not a mouse. Talk in a normal voice. What is my normal voice? They’re still waiting for you to say something. Say something!

“Hi there! My name is Rory, I’m a fourth-year medical student working with the doctor today. Is it alright if I start things off with you and the doctor will join us shortly?

***

The blessing and curse of medical school is that every single word and thought will be dissected, critiqued, and revised for four straight years. At the end of those 4 years students will graduate with a foundational medical knowledge and a dictionary of well curated words and phrases for you to use as you begin the next phase of training. Cramming all of this into a 4-year program is no small feat and no one hides the fact that this is supposed to be challenging. One advisor told me while I was interviewing: “The next four years is not the time to get married or adopt any new pets”. I imagine my wife, two cats, horse, and mini-horse would disagree with that stance. Regardless, like many students, I enlisted in this process because I wanted to help those in need. It was rapidly apparent that although I had the “why” figured out, I had conflated that with the “how”. I needed to determine how I was going to remain committed to my education even when it got hard—what was the one thing that was motivating me?

In my second month of didactic training, I was feeling overwhelmed by my cardiology instructor’s “it’s all just plumbing” analogy. As I pondered what part of the body would be the toilet (I had compelling arguments for both the mouth and anus), a thought entered my mind that would challenge my central reason for becoming a doctor: what if I don’t know something and I can’t help someone in need? Like this plumbing analogy, my solution was simple: just know everything! The magnitude of this statement was lost on me in the moment. This goal had one significant unintended consequence: I became extremely competitive. Unfortunately, despite occasional shining moments, there was a significant gap between myself and the future neurosurgeons of America. In order to overcome this difference, I had to set lofty goals that I had no chance of achieving. In some respects, this strategy did make me “better”. I learned the mechanisms of each epilepsy medication, memorized the Kreb’s cycle for a third time, and could accurately draw a Wigger’s diagram in less than 30 s. My understanding of medicine was better because of how competitive I had become and, by all accounts, I was succeeding at medical school. The plan worked … until it didn’t.

The foundation of my strategy was that I would always have someone to compare myself to. This was not a problem in didactics but would be my undoing as I started clinical rotations. It was not until I was the only medical student on a rotation that I realized how pathologic this strategy would be when I had no one to compare myself to. Additionally, I quickly found that my competitiveness made me really good at appearing smart. I had learned how to avoid the unknown and could intentionally steer conversations towards areas of comfort so that no one would ever see what I didn’t know. The first time I got the feedback “you need to read more”, I did what any self-respecting medical student would do: stuck my nose up at them and decided they had no idea what they were talking about. It wasn’t until the third provider offered this feedback that I thought maybe the problem was with me. It was time to face the music. Not only did I not know things, I didn’t know a lot of things.

So, I was at a crossroads. The knowledge gaps were piling up and I had to right the ship. I could try to be smarter than my attending, but that would be consigning myself to years of failure before I ever became triumphant. The thought of rethinking my entire strategy to surviving medical school was defeating. I had made it 2 years through the process, and it felt like I was going back to square one.

Along came my pediatrics rotation. A unique rotation in which students realize that all of their education was tailored to adults. An adult with a heart rate of 150 beats per min will set off alarm bells and sirens, whereas that heart rate is completely normal for a newborn. The pediatrics rotation makes you rethink what “normal” is. This becomes a daunting task because, as mentioned before, most of medical education is geared towards adults. I kept telling myself throughout the rotation, “get it right the next time”. At the time, I didn’t realize that I was inadvertently shifting my extrinsic competition-based source of motivation to an intrinsic model. Over the next few weeks, I would achieve new heights as I would build on the prior day’s successes and pitfalls:

Day 1: I correctly assessed every child’s vitals.

Day 2: Successfully looked in a crying child’s ear.

Day 3: Remembered to report medication doses by the patient’s weight.

Day 4: Recognized that, sometimes, that is just how a kid poops.

Day 5: Heard the murmur my attending was talking about.

Admittedly these are not the most earth-shattering accomplishments. Nonetheless, I became incrementally more confident and a better provider each day. Through this exercise, I learned to focus my attention on personal resolve—always trying to top myself—rather than on being better than the person standing next to me.

As a fourth-year medical student, I now have the luxury to reflect on the last few years of my education and I am confident to say: I got it wrong at first. Medicine is not supposed to be a competition amongst peers but rather a collaboration for the betterment of the patient. Fueled by competition, I set goals well outside my reach and my inability to achieve them led to frustration and unhappiness. Conversely, there is always success to be had if I focused on personal resolve; whether it’s beating your high score on an exam or just making a person laugh. Even when I miss the mark, I know there will always be another opportunity to do it better. Something even as simple as introducing yourself to a patient can always be done better. And every time you achieve your best, you will have a new goal to overcome.

Everyone is going to have their own challenges. For me, it was getting through and succeeding during medical school. Family, friends, and professional mentors are all there to help and support you through those challenges. Ultimately, however, it is your challenge and you need to decide how you will respond to it. Identifying your motivation is critical to achieving your goals and getting you through the lows. Jack Palance’s character, Curly Washburn, in City Slickers talks about the secret of life and says it all comes down to “one thing”. Just like the secret of life, I think battling through the challenges in life and finding the one thing that will motivate you no matter what is essential. What’s that one thing? For me, it was my pediatrics rotation when I discovered the effectiveness of deriving my motivation from within myself. But as Curly says “That’s what you got to figure out”.