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Avoiding the Shoals of Contracts and Codes

future, as the sliding doors opened to admit me to the cool, quiet air of the clinic. My heart sped with a mix of anxiety and excitement as I stepped inside, savoring the newness and looking forward to a time when I could savor familiarity instead.

The first patient I saw that first morning was a young woman with sciatic back pain. "I bent over to pick up a pile of books," she said, "and there was this sudden, terrible pain in my back. It shoots down my leg all the way to my foot." She was uncomfortable but not in crisis. It was a simple problem; a medical student would have known what to do. I gave her medication to reduce the inflammation and calm the pain. I told her what activities she should and shouldn't do, when to expect the pain to get better, when to call me if it didn't.

The interaction went just fine, but I don't know that I had ever been as nervous managing a heart attack or a massive stroke as I was with that young woman's sore back. I schooled my voice carefully to keep it from trembling. I double-checked the details of the prescriptions I wrote, which looked oddly unfamiliar on the fresh pad printed with my name. A question kept popping into my mind: What if what I'm telling her isn't right? I had to keep reminding myself that I did know how to do this. I'd had similar conversations many times during my training. But afterward I'd always gone to present my findings to my supervisor, getting either further advice or a stamp of approval. From here on, though I could and often would ask for advice from my colleagues, there would be nobody above me. I was on my own. With that first patient, I found that fact terrifying.

My second patient had a urinary tract infection and was a little easier. The third one was in for a physical exam, and soon I was so caught up in learning about her history and her concerns that it didn't occur to me to be nervous. By the end of the day, the fact that I didn't have to run things by anyone didn't seem strange. By the end of the first week, I had stopped even thinking about it.

My clinic is a large, doctor-owned group that includes almost all the medical

I could only begin to glimpse all that lay in my future, as the sliding doors of the clinic opened to admit me to the cool, quiet air inside. My heart sped with a mix of anxiety and excitement.

specialties. I chose it partly for this fact, so I'd have colleagues to talk to, to ask questions of, to learn from. I had completed four years of residency training on top of four years of medical school. I had passed the specialty boards in internal medicine. ("It's like being a pediatrician for adults," I explained to friends who didn't know what an internist was. "No kids, no OB, no surgery, but pretty much everything else.") I had the tools I needed, but there was a lot of practical, day-to-day knowledge I had yet to learn. They call it "practice" for a reason, I reminded myself.

The clinic building has several wings built at different times. Medical buildings, ever-expanding according to need, have always reminded me of swallows' nests—the structures of one era tacked onto those of the age before. My office was on the second floor in an older part of the building, its window looking out onto a quiet street and the steeple of a nearby

church. I had my own medical assistant and would soon hire a receptionist (whose title would change later to "patient service representative," as staff roles shifted and evolved like the building, like medicine itself).

I had two examination rooms—small and neat but a little dark. After years of rotating through exam rooms in the resident clinic, I realized to my great delight that these were mine to set up and outfit as I chose. I replaced the ugly industrial mirror in each room with a pretty, modern one, and I added a floor lamp. Suddenly the spaces seemed brighter and the note of dinginess was gone. I began to fill the walls with photographs, the plain yellow paint giving way to scenes of mountains and wildflowers. I put fuzzy covers on the cold metal stirrups of my exam tables. After a few weeks, I realized that the rooms no longer felt like exam rooms; they felt like my exam rooms. It was a subtle difference but a transforming one. My new life was beginning to take shape.

Asaving grace as I struggled to learn one new thing after another was that I had several friends from residency going through the same process. Periodically we would gather to debrief about the strangeness of this new world.

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