Competence has a very short memory
Every July, the hospital fills up with people who are terrified and (mostly) hiding it well.
The new fellows started at the beginning of the month, and our cardiology fellows are in the echo lab. After a gradual introduction, they're now doing complete normal echocardiograms on their own. I reviewed one with a fellow this week. It was technically perfect — and I told him so, more than once. But I could tell it's all still new. He isn't sure he can do the same thing at two in the morning, on call, scanning a sicker patient with no one standing at his shoulder.
What strikes me now, from this side of it, is how completely we forget. By the time you're the attending, the things that once terrified you have become the things you do while thinking about something else. You place the order, clear an inbox message, call a family, critique a fellow's study like is is second nature, in between the things that matter, seeing patients and reading echoes — and you no longer remember that each of those automatic tasks was once something you double- and triple-checked.
Competence has a short memory. It erases the record of how it was earned, and it flattens the long evolution underneath. I started out writing orders on paper charts and walking a carbon copy to the front desk. Now I place that same order from an app on my phone. Somewhere in between were a hundred small adaptations I couldn't tell you a single thing about.
That forgetting is a real gap in medical education. What stresses new residents, fellows, and attendings isn't the medicine — it's the day-to-day machinery nobody sits you down to teach. People who learn by watching and doing pick it up fast. People who learn other ways struggle, quietly, often alone. There's no exam-prep book for it, no academic half-day. You're simply expected to absorb it.
I've come to think part of my job — maybe the most important part — is to plan for that gap instead of pretending it isn't there. To tell a first-year, out loud and on purpose, that fumbling is not evidence they don't belong. To build a real check-in for new attendings, who get the least support of anyone and are somehow expected to need it least. The newly minted full professor is a beginner too; we just stop calling it that.
We are worst at teaching the things we learned by doing.
That's true of a fellow learning to read an echo. It's just as true of anyone standing at the start of something — a new title, a new city, a life you chose but haven't grown into yet. The beginning feels like proof you're not up to it. It is only what a beginning feels like.
I have written several blogs about career transitions. Every stage has one, and the transition in duties is the hardest part to navigate. There are links to a few of the more relelvant below in case you find your self at a transition.
Be gentle with the beginners this month. Every one of them — the intern, the fellow, the brand-new attending, the professor in a role they've never held — is doing something for the first time. You were once, even if you don't remember it.
— Ben
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