It’s 3:30 p.m., one hour until the evening resident comes in. “Today’s pretty slow today, that’s nice,” I chirp. These are the only words I’ve exchanged with my resident for the past three hours. Needless to say, the ambiance in the call room today is chilly at best.

“Fingers crossed.” The phrase is uttered with an almost automated quality, not unlike the signature clink-clank-plink of a souvenir penny being spat out with one final crank. I’ve found myself collecting phrases like this from time to time now. Souvenirs of intern year.

The interaction does little to warm the air, though. The truth is that today hasn’t been slow; between the last two admissions and four consults in the last three hours, on top of the three inpatients and two consults the two of us have already been following, we’ve been swamped. Well, I’ve been swamped. I’m not a neurohospitalist, I’m not training to be a neurohospitalist, I have no interest in being a neurohospitalist, but today I have essentially been asked to be one. Then again, this isn’t exactly unmarked trail I’m stumbling through; every off-service rotation has days like these. You just “roll with it” and learn as much as you can along the way. If I took every sour interaction I’ve had with patients, residents, and attendings personally, I’d basically be a lemon. So instead, I’ve learned to just be as sweet as I can, so at least by the end of the day, there might be some lemonade.

Though there are days that just can’t help but be bitter. This is one of those days.

On these days, I find it’s best to just be straight with it. I screwed up. The details of my mistake are sloppy, but ultimately not life-threatening or permanent. Just poor decision-making. It created a lot of extra work, unnecessary confusion, and left the patient and his family with a (gasp) bad impression. Nonetheless, it was an avoidable mistake, which is the type I really should be able to foresee and therefore avoid.

Alright, time to bite the bullet. 

“I know I made a bad call earlier. I kind of can’t even think of why I said what I did, all I know is that it definitely wasn’t the best thing to do.” Genuinely apologetic. The best kind of apologetic.

“Yeah, it happens. Don’t worry about it.” Genuinely dismissive. The best kind of dismissive?

“I wanted to know if there’s anything I could do. For future reference.” I’ve now gone from simply waving a white flag to carrying a giant “OPEN FIRE!” sign. I find that I learn the most with this type of sign, anyway. Fire away.

“Honestly?”

“Yeah, honestly.”

“Well, the best thing I think I can tell you is that it’s important to have an opinion.”

“That makes sense.”

“Yeah, so … make sure you have a real opinion before you open your mouth next time.”

“Got it. Thanks.”

Have an opinion. It echoes in my head. This isn’t the first time I’ve heard this from upper residents I’ve worked with. In fact, it isn’t even the first time I’ve heard it as an intern. I heard this same sentiment the first time I had practice interviews as a medical student. Have an opinion! Have a direction, a purpose, a driving force behind your questions, your treatment plan, your interaction with a patient. Be the driver, guide the horse, bring the boat into the dock. This is one of our core responsibilities as physicians. It’s a phrase said in probably a hundred different ways before we even set foot inside a clinic, while we’re still sitting in our bedrooms, cubicles, coffee shops, or wherever else we studied for Step 1. The entire point of our feverish study is to have an opinion. So have one, a strong one, and have good reasons for having it. There’s a small problem with this message, though.

Sometimes, I still don’t feel like I have permission to have an opinion.

I know that I should. I have the degree, after all. Beyond that, I have “the job.” I’ve been through the Match, I’ve passed the exams, I’m even placing the orders. I have every right to have an opinion. A professional opinion. And yet, I really don’t feel all that comfortable having one most of the time. In fact, I feel less opinionated and less sure about my expertise each day. It’s a classic case of impostor syndrome. At some point, we get stuck swinging from, “Am I good enough now?” to “I’ll never be good enough, ever,” to “Holy crap, I’m a GENIUS.” Also at some point, we’re supposed to magically discover that the real truth is a mix of all three. But it’s days like this where I feel like I’m still not even ready to sit at the table. I don’t have that permission.

“Look,” my resident has clearly noticed the cloud of self-pity and disappointment that’s appeared over my head. “It’s OK to be wrong. But you need to realize that what isn’t OK is to be wishy-washy. You’re a doctor now. You graduated, you get to have an opinion. You should have one. So just make sure it’s a good one. If it’s wrong, that’s why we run it by the attending first.”

That’s true, I did graduate. I graduated medical school. I have a medical degree. I have permission. I have years of permission. The more I think about it, the more I realize how ridiculous the feeling is.

“And,” she quips, “if it makes any difference, I give you permission. Don’t be afraid to run it by me before taking it up with the attending. It’s no big deal. We’re all learning.” 

We’re all learning. We’re all at the same table. You have permission. Take a seat. Have an opinion. The ambiance in the call room has become a bit less chilly. One might even say it feels a bit warm and a bit fuzzy. It’s nice.

Driving home, I try to remember the day I graduated. I try to remember how it felt to hear my name, to be congratulated by my friends and family, and to open that sealed envelope with my degree inside, signed, stamped “MD.” I have permission. I’ve had permission since that day. It’s good to be reminded though, from time to time, by those who have gone before me. And it’s just as heartening to hear it from a resident who’s maybe only a year ahead as it is to hear it from an attending with decades of practice under their belt.

So I’ve resolved to pay it forward. As the new intern year starts up, I’ve decided to make it my goal to be vocal about giving interns permission to have an opinion, while emphasizing the awesome responsibility that comes with having that opinion. To be active about reminding them of their accomplishments, their competence, their ability, and to welcome them to have a seat at the table. After all, we’re all learning here.

Do you remember the first time you felt confident in your medical opinion? Share your memory in the comments.

Tim Hsu, MD is a big ball of yarn. He spends most of his time being batted around by his cat. In his free time he reads, plays video games, and occasionally gets some work done. You know, just a typical psychiatry resident. He is a 2020–2021 Doximity Op-Med Fellow.