Turn and Face the Strange

David Bowie, I respectfully thank you. May you rest in peace. I’d like to review and reflect on the lyrics of “Changes,” one of Bowie’s most well-known songs. As I was sitting in my deer-hunting stand in November, I reflected upon the past year of my life. I asked myself the intangible questions and contemplated the meanings of my fluid answers:

Where am I, where was I?

How am I, how was I?

Who am I, who was I?

Why I am, why was I?

Of course, there are no right or wrong answers; truthfully, it is an exercise of introspection, for personal emotional development. But the transitions we experience in our growth as female physicians (and physicians overall) are fantastic and offer so much in reflection and appreciation. If you haven’t given yourself a minute or an hour of quiet reflection, in our theme of growth, I suggest you consider those questions and answers.

Now, back to some Bowie. Exploring the first line of the song “Changes,” he begs us to answer the question, “What are you waiting for?”

Still don’t know what I was waiting for and my time was running wild…

Like many of my peers, I have battled with and strive daily to conquer the self-doubt and insecurity of impostor syndrome. Have you ever an uneasy feeling or tidal wave of insecurity as your colleague rattles off new data about the diagnosis of your patient? Do you feel as though your peers are all smarter and more deserving than you? Or worse, that you’ll be found a phony and people will realize you should not be an EM physician? Impostor syndrome affects many EM physicians, men and women alike, although it is more common in women according to some sources. Regardless of where we are in our career or training, we have all put in the time and effort to be there, be it in applying to or graduating from medical school, getting into residency, or graduating from fellowship. What are we waiting for? What do we need to accept that we are prepared and trained physicians?

Bowie goes on, for the sake of this article, discussing an impostor syndrome.

A million dead-end streets and every time I thought I’d got it made it, seemed the taste was not so sweet…

As a new, excited, and terrified intern, impostor syndrome is understandable. Perhaps the taste of starting your EM residency was not so sweet. Being new to medicine, learning the pecking order, and developing that thick skin needed to survive an EM shift is tough to say the least. But throughout the years and experiences of residency, many of us work through it and conquer it—that is, until we become an attending. When that next level is finally reached, will the taste really be so sweet? I found out quickly after graduating fellowship that there are many levels to impostor syndrome. It is analogous to a video game: I had beaten the intern and senior resident level imposter, yet the reward wasn’t like Super Mario Bros where I free the princess from the villain…the reward was attending level Impostor Syndrome, with capital letters. The hardest level thus far.

The transition from medical student to EM resident is palpable. It is audible. It is visible. It is tangible. It is simultaneously joyous and somehow sorrowful, ultimately freeing and tightly binding, absolutely terrifying and completely exhilarating. I walked into my first attending shift with palpitations, sweaty armpits, and shaky speech, but after the first couple patients I hit a shallow groove and guardedly realized I was actually prepared and capable. I felt pretty good about myself and my impostor was shrinking, getting squashed by my blossoming confidence and developing EM practice. Until my second shift (or was it my fourth?) where I encountered the salty, more experienced, and ever-resistant hospitalist who refused to admit my patient. I said what I thought I needed to say, I advocated as best as I could, but even after speaking with a couple hospitalists I kept hitting a hard and solid “no.” I could not get my patient the hospital admission he needed. Unfortunately, I was working solo coverage. I did not have an experienced EM physician nearby for consultation and guidance. But I did have a resource: the salty, experienced EM charge nurse. What a fantastic find and ally! “You need the administrator on call,” he calmly guided. What? It’s my second (or fourth) shift! I cannot possibly get the administrator on call during the embryonic stages of my career. But there I was, unable to provide what my patient needed, unable to navigate the waters of the new health care system, and hospitalist without a lifeline from the administrator on call. The impostor was growing and spreading throughout me toxic and swift, like a necrotizing fasciitis. I was able to speak with the administrator on call off the record and, thankfully, we resolved the situation with a positive outcome for our patient. Overall it was a great learning experience for not only the new EM attending, but for the system, and even the experienced hospitalists. Maybe it would have happened to a seasoned EM physician—likely not—but I survived to work another shift and serve another patient. Bowie sings on,

So I turned myself to face me, but I never caught a glimpse, of how the others must see the faker, I’m much too fast to take that test.

Impostor defeated or at the very least put into the shadows and shushed.

Ch-ch-ch-changes, turn and face the strange.

The strange, indeed. Working solo coverage in an ED days, weeks, or months out of the comfortable and cozy nest of EM residency is strange in many ways. Everyone calls you “Doctor.” When you say you see free fluid or lung slide on a FAST, or a drainable abscess or DVT on POCUS, it is taken to be there and be real. It is not questioned, nor double- or triple-checked by the senior resident and attending. The attending is you. People of all sorts—patients, nurses, respiratory therapists, paramedics, community members—look to you for knowledge as the guide, for confidence as the leader, and for skill and competence as the EM physician. To cope, I have done some reading and listening on impostor syndrome. I have talked with fellow EM physicians when on shift together, and have created my own positive mantras to review before, during, and after shifts. Knowledge, support, and positive talk have all helped immensely. It was surprising to share some of my fears with colleagues and realize so many have the exact insecurities and daily battles, even those 5 or more years out of residency. Impostor syndrome truly is a common finding amongst us EM physicians, and it truly is manageable—if not conquerable.

“Don’t want to be a richer man, just gonna have to be a different man,” Bowie eloquently states. I think he was talking about his career, really, but he is talking about mine and yours too, and maybe our life in general. Growth. Evolution.

Time may change me, but I can’t trace time.

I have only been working as an attending for 5 months but have learned each shift is a different emotional and academic experience. Each shift and patient encounter offers different opportunities and growth for me as a new physician. I have a different level of confidence and worry; some days I feel great, as I am so prepared and capable to serve my patients. Others, I am looking things up for the 100th time (that shift) and feeling insecure in my decisions, and I leave feeling my impostor syndrome grow. I practice my positive self-talk and my mantras and find comfort in sharing stories with colleagues. Time may change me; I hope it does, in a way. I hope with more time on shift and more patient encounters, my impostor syndrome fades.

I watch the ripples change their size, but never leave the stream of warm impermanence.

The second verse comments, perhaps, on my personal life’s growth and evolution. My recent wedding and the wonderful addition of a husband and 4 stepchildren to my life has been a leap in the area of personal growth. Becoming an instant family is a daily adjustment. At home, I watch my stepchildren grow or “change their size” physically, cognitively, and emotionally. However, it is not permanent: one day of knowledge acquisition and eager learning with emotional maturity will be followed by another of disinterested quiet, distanced communication, and seemingly unprovoked pouting.

And so the days float through my eyes, but still the days seem the same.

I watch our family grow together, blending and learning our family dynamics and creating lasting memories to bond us for our lifetimes. We are still developing our routines, so the days seem the same and we can all find comfort in our family habitat. Nightly when not on shift, I find comfort and routine in tucking in the younger kids at bedtime, discussing their days’ events, and ending with, “Goodnight, I love you,” and hearing the precious, “I love you too.” I look forward to the consistency of high school athletics, the daily practices, and “can you please pick me up?” texts at 5 pm followed by a voracious snacking when we get home.

And these children that you spit on as they try to change their worlds are immune to your consultations, they’re quite aware of what they’re going through.

It amazes me what children are aware of and what they perceive; they really are always listening, learning, and taking cues from adults and each other. My stepchildren are between the ages of 8 and 14 years old, no diapers or highchairs in our home. We didn’t experience the typical family growth of a pregnancy and a newborn, but a different load of stressors and new demands. In my brief experience, I believe the clichés for happiness at home are solid truths: communication, flexibility, understanding, and love. Open and honest communication fueled by love between my husband and myself, and myself and my stepchildren, keep our home a functioning and supportive environment for our family system to flourish in. Our children are quite aware of what they’re going through, and they are actively trying to change their worlds. It is beautiful and wonderful to be a part of their growth and development. However, no family is perfect. Each day is not a magical and wonderful day, but we learn from and communicate through our tough days. Resilience is taught, demonstrated, observed, and learned—especially during hard days or hours—sometimes from the adults, sometimes from the teenagers, even sometimes from the youngest child. We are all trying to change our world. Similar to the universality of impostor syndrome at work, the adjustment and the strange aren’t mine alone; my husband is learning his role as husband and co-parent, while our children are learning how to have two adults parenting and setting expectations to be met.

Ch-ch-ch-ch-changes. Turn and face the strange.

It is a common saying that growth occurs outside of our comfort zones. Growth is strange and uncomfortable indeed. Becoming an attending, the conclusion of formal training, closes one door and forcefully opens the next, exposing a worried attending learning with each patient encounter and slowly beating impostor syndrome while developing her EM practice. The conclusion of a single woman’s adventures starts the story of a new stepmother and wife, learning the majority of her activities at home are for the benefit of her children. A woman watching her grocery bill jump to over $300, her free time plummet to nearly zero, and learning the value of “because I said so.” Along with the hard lesson that one pound of ground beef simply does not cut it for dinner for a family of six. I am working to confront changes in my life, confront the impostor at work, and experience my personal and professional growth with an attitude of exploration and healthy dose of optimism. As the poetic David Bowie states, “Strange fascinations fascinate me, ah, the changes are taking the pace I’m going through.”

I said that time may change me, but I can’t trace time.

By Alecia Gende, DO, CAQSM