Advice for new doctors - how to start strong in residency
The end of June and beginning of July marks the start of a new medical year—when freshly minted interns take their first steps as doctors, and new roles begin for residents, fellows, and attendings.
Around this time, there’s always a flood of advice on how to make the transition from med school to residency.
Some of it’s useful. Some of it’s noise.
In my experience, advice for new doctors tends to fall into three broad categories:
How to do clinical work and take care of patients
How to choose a specialty
How to turn your career vision into reality
This piece is about the first one: how to take care of patients and do clinical work well. The others can wait.
I’m qualified to write about this topic because I spend a lot of time working with new doctors
I spend a huge part of my professional life training residents.
I work with them on the wards. I observe their growth. I hear about what feedback and coaching that they’re geting. I think deeply about how to help them get better.
Over the course of each year, I have nearly 50 individual feedback sessions with residents I’ve worked with directly. I serve as a co-chair of our Clinical Competency Committee and sit on our program’s leadership team.
I’ve seen residents thrive. I’ve seen residents struggle. And I’ve learned a lot about what makes the difference.
This isn’t a list of life hacks - it’s a reflection on mindset.
By the time people make it to residency, they’ve been filtered out based on IQ points. Everyone is smart enough. And the difference between the best doctors and the other ones isn’t about intelligence.
Attitude shapes everything: how you learn, how you take care of patients, how you build a career, and how you’re perceived by the people around you.
So here’s the meta point: attitude is destiny. Aptitude is not.
You don’t need to be more confident. You need to be more decisive
Many smart young doctors agonize over their clinical decision making.
They see the patient, check the vital signs, review the labs, look at the scans, and then second guess themselves.
They hedge. They defer. They stall.
That’s normal. There are tons of ambiguous clinical situations where multiple options seem reasonable.
And the feedback these residents often get? “You need to be more confident.”
I think that’s the wrong feedback!
You shouldn’t be confident yet. You’re just starting out. You don’t have the reps.
But here’s the thing: you don’t need to be confident to be decisive.
Making decisions is how you learn to practice medicine. See the patient. Weigh the data. Then make a reasonable decision. You can always adjust.
Most medical decisions are reversible. The marginal benefit of agonizing over creatinine trends or re-reading UpToDate for the fifth time is minimal.
The benefit of taking action and learning from what happens next is that’s how you get better.
Confidence comes with experience. But decisiveness is a skill you can practice from day one.
Work Well on a Team
Clinical acumen certainly matters, but your ability to function as part of a team - and to elevate that team - might matter more.
Don’t be an asshole. Don’t be a pain in the ass. Don’t be a squeaky wheel.1
Your job is to make the day go better for your patients and your team. That means nurses, med techs, pharmacists, case managers, social workers. Everyone.
Ask “How can I help?” Be the person others trust on a busy day. If you’re complaining all the time, people will notice. And if you’re uplifting the team, they’ll remember that too.
Here’s a simple test: Are you elevating the experience for the people around you? If not, rethink your approach.
Medicine is a team sport. So is research. No matter what path you choose, you’ll need people who want to work with you.
Take care of patients like people. And remember that every person is different
Your job isn’t to sound smart. It’s to care for the human in front of you.
That means being present, being patient, listening, answering questions in plain language, and offering guidance without overwhelming. Hospitalization is one of the scariest, most disorienting experiences someone can go through. Don’t make it worse by talking like a textbook.
Your job isn’t to persuade patients that you’re right. It’s to help them understand the big picture and to recommend a course that aligns with their goals.
There’s a huge asymmetry in information, even for the most health-literate patients. If you just present a menu of options and ask them to choose, you’re pushing decision fatigue onto someone already stressed and afraid.
But if you know their goals, understand their beliefs, and guide them clearly, you’ll help them make better choices.
Every patient needs something different from us. You can’t show up as the same person in every room. Learn to read the room. Adapt your style. Meet people where they are. That’s what makes you good.
And one last thing:
Doctors are judged like actors in a play, not a movie.
You’re judged on each live performance. No one cares how well you did yesterday. What matters is how you show up today.
You learn the most from your patients
Marty Blaser, who was the old chair of medicine at NYU used to start every case conference by saying:
“Medicine is a process of always learning. You learn the most from your own patients, and sometimes you can learn from someone else’s patients.”
I didn’t totally get it back then. But now I know how right he was.
Patients don’t read the textbook. They present in unexpected ways. Taking care of them teaches you the natural history of disease, the impact of treatments, what to read and what to question.
Patient care is how you internalize clinical patterns, see treatment effects in real time, and understand where guidelines fall short.
Clinical medicine is a spiral staircase - you see the same conditions over and over again, and each you take care of the same diagnosis, you see it from a slightly different perspective.
Learning something, forgetting it, and then relearning it is how we work. It’s how understanding deepens. Each time it sticks better. Each time it becomes more integrated into how you actually practice.
You’ve heard the phrase “you are what you eat.” Your mind is what you read and your information diet becomes how you think
You need to always be reading and learning.
But don’t fool yourself into thinking that you’re going to have a 3 hour chunk of time this weekend to catch up on your reading.
You won’t. Ever.
If you don’t build a sustainable, bite-sized learning system into your daily routine, your reading list will just become a pile of PDFs that taunt you from your iPad six months from now.
My granular advice: reading isn’t about finishing an article. It’s about learning something from it.
One of the easiest ways to make it stick? Tell someone what you learned. The faster you move it from reading to explanation, the more likely it is to last.
Learning is another spiral staircase - you read about the same things over and over again, and they mean different things to you as you develop more experience. And the specifics of what you read will change as you get more comfortable clinically.
Start with pre-digested, high-trust sources: The Massachusetts General Handbook, UpToDate, or well-written review articles.
You can skip the RALES trial for now. Try to understand the basics: epidemiology, pathophysiology, treatment, and prognosis.
As you revisit topics, start reading the landmark trials.2
But don’t stop at regurgitating recommendations or flowcharts from the guidelines - if just blindly quote guidelines and flowcharts, you’ll turn into an algorithm monkey that’s going to be replaced by ChatGPT.
And be careful about what you consume: most new research isn’t worth your time. Don’t poison your mind with crappy observational research that’s hopelessly confounded.
Use a large language model to help identify that landmark trials for the management of conditions that you see regularly, and then read those papers.
Amateurs talk strategy. Professionals talk logistics
The difference between “kind of” knowing something and actually knowing something is massive.
Being able to describe the big picture concepts in management is easy.
Lots of residents know that you should treat a heart attack with blood thinners and consider taking the patient to the cath lab.
But the specifics of what precisely you do are the difference between someone who knows what they’re talking about and someone who is just an experienced non-expert.
Do you load with two antiplatelet drugs up front? Does the patient get a beta blocker? Do you get an echo before the cath lab? Should this patient actually just have a stress test instead? Do we really think it’s a type 1 MI?
Knowing the theory behind a diagnosis is one thing - and that’s the easy part.
Knowing how to actually treat it - the order of operations, the practical management, the dosing, the specifics of the when and how - is what makes you a pro.
You get there by managing the same common problems over and over.3
If you don’t master the mundane, you’ll miss what matters. For every zebra you diagnose, you’ll see a thousand horses. And if you’re bad at managing horses, no one will care how good you are at spotting a zebra.
Keep a growth mindset. And remember that most feedback isn’t labeled as feedback
You can only become a great doctor by constantly getting better.
That means being inquisitive. Asking good questions. Reading the landmark papers 10 times instead of just once.
Getting better means paying attention to feedback. And the vast majority of feedback that you receive is not labeled as feedback.
When an attending disagrees with your management choices - that’s feedback on your decision making
When a patient asks a question that makes it clear they don’t understand their diagnosis at all - that’s feedback on the way you explained it
When your med students or interns are on their phones during your teaching session - that’s feedback your teaching isn’t connecting
When the patient doesn’t get better with the treatments that you thought they should - that’s feedback on your clinical reasoning
When the CT scan shows a finding that you didn’t consider - that’s feedback you closed prematurely
When the consultant disagrees with your management decisions - that’s feedback that your depth of knowledge about that disease might not be as comprehensive as it should be
Most of the formal feedback that you receive is generic, insipid, and useless.
But if you read between the lines of your day to day work, you’ll realize that there’s a ton of feedback there for you to use to get better.
You don’t need me to tell you what facts you know and what facts you don’t. You can figure that out yourself.
Pay attention to how people are responding to you and how your patients are responding to your treatments and communications.
Don’t let someone else do you thinking for you
Calling a consults or running a case by your attending are valuable but they’re not a shortcut for turning your brain off.
When you call a consultant, you should already have thought about a point of view. Know what you think you should do.
And if they have a different perspective, And when they disagree with you, figure out why you put a different weight on the factors of the case than they did.
Evidence beats mechanism
Mechanisms are neat. They make us feel like we understand the biology well.
But most of the time, our mechanisms are overly simplistic of flat out wrong.
Never forget the CAST trial.
Flecainide suppresses PVCs after MI, so it should improve outcomes, right? But it also makes people more likely to die.
When hard evidence contradicts the mechanism, believe the evidence.
Final Thought
Residency is hard. It’s long. It’s exhausting. But it’s also when you become who you are as a doctor.
Show up with the right mindset. Be decisive. Take care of your patients. Elevate your team. Stay curious. Do the reading - the right kind. Think for yourself. Learn from your mistakes. Adapt. Teach. And never settle for “good enough.”
You’re not just here to survive. You’re here to become excellent.
The way you treat the people around you, particularly those who are lower in the hierarchy of the medical system, is a real window into who you are as a human.
And you’ll find that some of our guidelines are built on a house of cards of flimsy evidence.
Also, please stop overthinking hyponatremia. It’s always SIADH unless the patient has heart failure or cirrhosis. And then it’s still probably SIADH.
Hi Greg! Wasn’t able to comment on the publication itself, but enjoyed the read! I’ve worked in cardiology at an academic medical center for the last 10 years. Lots of value here for NP students entering the clinical portions of training and new-graduate NPs transitioning from the RN to APRN role as well. Thx for sharing.