S7E24: Prelim Year, Unfiltered

Lilly: I've decided that I have a new threshold of who my true friends are from just how honest they are with me. The other week, I went to the ED and I saw Shima. She told me I looked a little different, and I told her I had a different foundation shade. Shima, what did you say to me?

Shima: I said, "It's a little bit too dark."

Lilly: For real, it was too dark. And guess what? I wore that the whole week, and no one had told me that it was too dark on me. Anyway, that weekend I was able to get my shade corrected. So thank you, Shima. That's how true friends should be with you. I appreciate that.

Shima: Of course.

Lilly: Welcome back, Bundles. It's Lilly, one of your co-hosts. I am super excited this week to be joined with three of the most beautiful prelims that I work with. For those of you who don't know what a prelim is, this whole episode we're going to do a deep dive and tell you all about our experiences being prelims.

So before we dive into that, I just wanted to do quick introductions with each of the three lovely ladies that are joining us. So we'll start off with Jenna, if you don't mind introducing yourself.

Jenna: Hi. I am so happy to be here. A long-time "Bundle of Hers" fan. I'm Jenna. I'm an ophtho prelim, or I guess I'm a prelim in medicine doing ophtho. And I'm from West Valley, which is part of the greater Salt Lake area. Went to med school with Lilly, and did residency, stayed in Utah.

Lilly: And then we'll have Lena introduce herself.

Lena: Hey, guys. I'm Lena. I'm also a prelim doing an ophthalmology residency here. I'm coming from University of Michigan as my med school, and I went to University of Michigan-Dearborn for undergrad. My ethnicity and family background is Syrian-Arab.

Lilly: Awesome. And last but not least.

Shima: Hey, everyone. I'm Shima. I'm also a prelim ophtho, and I'm originally from Iran, where I completed my medical degree. It's been quite a fascinating journey transitioning here to Utah, and I'm very excited to share my experience and be with you all.

Lilly: Yay. I'm so excited to have you all on "Bundles" so that we can chat more about what a prelim is and what it's been like.

Before we dive into our conversation, I just want to give our usual disclosures. All the opinions that we share on "Bundles" are those of our own. They don't reflect any kind of employer or institution that we represent.

So with that all in mind, we're going to chat about being a prelim and what that means. For those of you who are in undergraduate right now, or you're a medical student, or maybe you're a newly matched medical student, in which case congratulations, you'll be joining us soon in residency, you're probably wondering what the heck a preliminary resident is.

So for those of you who might be interested in going into radiology, PM&R, ophthalmology, neurology, dermatology . . . Am I missing any? Anesthesia. You'll most likely be doing a preliminary year in either internal medicine or surgery prior to starting your specialty of choice. And this is meant to give you a foundation before you go into your specialty.

But a lot of times, for people like me at least, you don't even realize this is an option when you're choosing your specialty, and it kind of comes as a shock as you're figuring out what you want to go into as a third- and fourth-year medical student. Then you realize you have to dedicate a year of your life practicing in a field that you will not be licensed in, nor one that you'll be practicing in as an attending physician one day.

A really weird other minutia detail about medical school and medicine that you don't really learn when you see fun TikToks of people in med school, but something that you learn to navigate as you go through med school.

So it's something that I wanted to chat about today as someone who had no idea what this meant and how to prepare for it.

I think each of us had very unique experiences going through the medical system, whether we stayed at our home institution, came from out of state, or came from out of the country and are experiencing all the different types of challenges and uplifting moments that happen in residency.

I first just wanted to start off a little bit chatting with Lena, being an out-of-state resident for us, just to tell us a little bit about what your experience has been like, coming to Utah, being a prelim, and all those fun things.

Lena: I've loved moving to Utah, coming from Michigan. It's definitely been a journey of a lot of self-discovery. I'm far from my family, but my family, particularly my parents who are both in medicine, had both strongly encouraged me to rank this program highly knowing that I'd be far from them. But they knew that residency was just as much about the environment as it is about the training, and knew how happy I was after my interview here, how well I felt like I fit.

And they definitely were right, because with Utah and the program here, I've definitely been able to have the structure to grow but also have the support to thrive.

I've also learned that community is something you build with intention as much as it is that it's something that you find in unexpected ways. So I didn't know anybody moving to Utah, but I made effort to connect with co-residents but to also connect with the larger Arab and Muslim community in Utah. And it's been a beautiful experience. I'm so grateful to be here.

Lilly: I feel like Lena is truly a social butterfly. I feel like you know more of Utah than I do and you've been here for such a short time. But Lena's also built different, guys. She will go on two-hour hikes after night shifts, so I think we all aspire to be Lena.

Jenna: I have to shout out to Lena because she won the mountain climbing contest in our residency, the PGY-1 winner.

Lilly: Good point, Jenna. She really held it down.

Jenna: Yeah, she really did. I went on a hike with her, and I was thinking, "Lena's not from here. I'm sure I'll be fine." No. She whooped my butt. I was dying. And I had been hiking a lot in recent times, and I could not catch up. I was like, "Lena, I need a break."

Lena: I learned after that hike with Jenna that I could double as a motivational coach. I'm like, "Jenna, come on. We got this."

Lilly: No one is more awake and thriving on night shifts than Lena. Truly, I cannot relate at all. I am a zombie.

Kind of going off of that, Jenna, what has your experience been like being someone who went to medical school here and now you're a resident here? Has that been any different, or do you feel like you're a forever medical student? Which is something I was really nervous about in trying to decide if I wanted to stay or not. What has your experience been like?

Jenna: I think there are a lot of benefits to staying in that you feel more comfortable and familiar with the place you're at, and you have the benefit of the support system you already built here.

I think you get a lot of advice as a med student to leave. I don't know if you heard this a lot, Lilly, but people were always telling me to leave. And I didn't like that very much. But I understand it's people's own experience, and that's where they're giving that advice from.

But I think my experience has been really mostly very positive, I would say, and I thought the transition from med student to resident went pretty smoothly.

It is hard. We match early in ophtho, in February, and so I had several months on rotation as a med student after matching. And during those months, I did feel a lot like, "Oh, wow, the pressure is on because these people are going to be working with me, so I cannot be a lackadaisical fourth-year." Which is not a big deal.

But yeah, I think it's actually gone pretty well. I have no complaints about it. What was your experience like, Lilly? I guess you did the same thing, of course.

Lilly: I know. I was actually thinking about . . . I remember there were some attendings I worked with when I was a med student that I was like, "Man, I really hope I don't have to work with you again one day." And then there were other attendings that I was like, "Oh my gosh, you're the reason that I'd want to stay here. I want to learn more from you."

So it's been really cool because I've done both. I've worked with attendings who I felt like I didn't have the best experience with as a med student.

And it's kind of interesting how I do feel like they treat you a little bit different when you're a resident because suddenly . . . It's kind of funny because it's only been, what, two months in between that time. But suddenly, you're an intern who can order medications and talk to consults and all these things that med students . . . I mean, we do, but we don't do as definitively.

I felt like sometimes they just respected me a little bit more, which was really interesting. And then there were other attendings who I worked with as a third-year medical student where I didn't know anything. Like, "Please don't ask me to explain an AKI to you. I'm absolutely petrified," to now working with them on service, carrying double the amount of patients I used to.

And I remember one of my attendings . . . He's one of my favorite people. It's Dr. Hallowell. I don't know if you guys have worked with him at IMC at all, but he is just a lovely human being.

I remember I was talking to a patient in Farsi during our rounds, and when we left the room, he was like, "I'm going to cry. I'm just going to cry. That was so beautiful." He speaks Spanish, so he's always talking to patients in their native language. And no one ever really gives us a chance to talk in Farsi, so I was like, "This is my moment."

I just remember him being like, "This is what it's all about. That made me so happy." And I was like, "Wow." These are the kinds of attendings that really make you want to stay where you're at and feel like you're really being valued for who you are.

So I think on that end, I was more scared of being treated like a forever medical student and just kind of being treated like I was a fourth-year, and maybe them questioning a lot of my medical decisions, which I think is totally valid. We're still trainees, and I want them to question my decisions because I don't really know all the time what the right choice is.

But at the same time, I feel like they do give you that respect of, "You're a doctor now and we want you to feel like you have that autonomy over your patient," which has been really nice.

Jenna: For sure. And the beauty of being a prelim, you can be like, "Yeah, I don't understand this AKI. Can you please explain it to me?"

Lilly: Or they're like, "How can I possibly relate this to neuro for you?" And you're like, "That's a great question. When will I see this in practice? When will I manage this?" That's a very good point.

Going all the way across the country with Shima, what has your experience been like, not only coming from a different institution but also coming from a completely different place and a completely different residency?

Shima: Being at IMG, it involves lots of things. This comes with its own unique challenges, opportunities. It's lots and lots of transition into a new healthcare system, your comfort with different patient expectations, and there's also sometimes a different communication style. The language is different.

But on the other hand, it's incredibly rewarding as you see how interesting it is when you bring your diverse perspective or you use your foundation from your previous training.

For me, it's been a journey of continuous learning and continuous adaptation. It's been quite beautiful, I think. But it is challenging at times. It's not always butterflies.

Lilly: For sure. What do you think is the big standout to you your first month when you were in residency that you noticed, "This is something that's really different from my home institution"?

Shima: Since the values are somewhat different, it depends on how you define respect and care. Words that I use to convey my respect and care for a patient or for a colleague are not necessarily the same language they use.

It was so interesting for me that when I initially came, there were such nice people, they were so nice, but I sometimes got lost in, "So is there something you want me to do, or is there not something that you want me to do?"

Lilly: Fair. That closed-loop communication of "Let's get this done," or "I'll take care of this, you take care of that."

Shima: Yeah, things like that.

Lilly: Yeah, that's fair. I think sometimes also I'll notice in a team or something, we'll say, "Oh, we need to do this," or, "We need to talk to this person," but then nobody really knows who's going to do it. Is it me? Is it my senior? Is it my attending? Especially with really complex things that you're not as privy to as a medical student.

One thing that I've had a really hard time with is figuring out disposition and working with case management and social work and figuring out insurance, and medications, and safe discharge, and what will be covered, what won't be prior authed. All of those things, I just didn't really see it all as a med student.

I knew they were happening in the background, but now it'll be like 5:30 and we're about to get an admission and I'm trying to figure out a medication reconciliation on this patient. I have no idea how to use this EMR and the pharmacist already left for the day. And I remember asking one of the case managers how I can figure out something, and they were like, "You just do it." I was like, "Oh, okay."

Jenna: That's intern year summed up.

Lilly: Truly. My senior is busy, my other intern is busy, my attending is seeing someone else, and I'm just like, "I need to figure out this thing that I've never, ever had to figure out before." It's like snail mail. You spend probably triple the amount of time that the attending or anyone else would on trying to figure this out.

But it's kind of on you and you're just like, "Who do I ask for help?" Usually, there's someone to ask, but also sometimes it's hard to figure out what our role is and what our role isn't. Sometimes I'll tell my senior about it later on, and they'll be like, "Oh, this person should have helped you." And I'm like, "Well, I didn't know that."

Shima: That's actually what inspired me to make an intern sign-up manual. And it was mostly inspired by people asking me to do things that no one knows how to do. There are no instructions for it and there's no specific person that you have to reach out to. You just find out by trial and error.

It's quite interesting. You meet lots of people on the way of figuring out how to solve these problems, but it did inspire me personally to make that spreadsheet that if they call you for that, this is who you would call, and then you should call them, and then you should write down this, just to make life easier for the next person, hopefully.

Lilly: Wait, Shima, that is so nice of you. I need this spreadsheet. I can't believe you made this at your free time.

Jenna: It's ophtho-specific, so it might not be that helpful for you, Lilly.

Lilly: Oh, nevermind.

Jenna: It's very helpful for our future incoming interns.

Yeah, I think Shima brings up a good point, and Lilly too, about so much of what we do as interns is this unspoken legwork that you already knew was happening but we didn't really realize until you have to do it. It's like, "Oh, it's really a lot of effort."

And I think that's the hard thing about being a prelim, is because you're also doing it knowing, "I don't need to know this really, but I have to do it for right now."

But yeah, discharging a patient at the VA is a perfect example of a painful, arduous process, and that really, as a prelim, can suck the life out of you.

Lilly: Yeah. I think there was one time I was trying to transfer a patient from the VA, which is the Veterans Center for Medicine, to our main hospital, and it literally, I kid you not, took six hours. By the time she left, I wanted to cry because I was like, "I can't believe I spent six hours trying to get this patient the care that she clearly needs." But also, it just needs to be so much better streamlined.

Jenna: For sure. There's so much unspoken knowledge, and your senior knows because they're like, "Oh, yeah, we learned how to do that." Yeah, it's interesting.

Lilly: Totally. I think that a lot of times people say prelim year is what you make of it, so I went into prelim year telling myself I was an internist. I was going to be an IM doc. And I think picturing it that way was really helpful for me, because I didn't hate medicine when I rotated through it. I was just super intimidated by it, because you have to know so much about so many different organ systems.

That was the reason why I didn't end up pursuing internal medicine. I was like, "I think I want to be a little bit more sub-specialized." And neurology in itself is also a huge umbrella that it's also very intimidating.

But I think going back to now when we're almost done with intern year . . . which is also terrifying. I can't believe that happened so fast. I'm also wondering what is it going to be like going into our next year when we're actually in our field?

And you all kind of have this unique experience of getting a little bit of that exposure, which I haven't had yet. So I was curious to think about what has that been like? Do you feel like you guys have had enough experience seeing your ophtho residency this year? Do you feel prepared for next year? What has it been like?

Jenna: Lena and I, I think, are laughing because we literally saw each other a few hours ago and were talking about how we are both so scared of next year. It's kind of doing intern year twice in a way. There's just so much systems knowledge, like we were just talking about, and technical skill that we just lack, and just general knowledge.

So, yeah, I'm very intimidated by it. I think I'm in the head space right now where I'm like, "Oh my gosh, I have to be the primary person on call and for the whole hospital for ophthalmology knowledge. Whoa, that's a big step up from our current situation."

Lilly: That is. Lena, what did you and Jenna talk about? What was that like?

Lena: We were in neuro clinic today, and we were trying to brainstorm how to best prepare for next year. It's definitely a big step for us, but I remind myself that the transition from med student to intern prelim was also such a big step. But you have to have the humility to know, "There's so much I don't know. I have to ask when I don't know, even if it's embarrassing or I feel like I should know it," and that patient safety always comes first.

One of the biggest lessons I've learned from this year is that medicine is so much less about knowing everything but it's more about asking the right questions, truly understanding your patient.

When Shima was talking, it kind of got me thinking about how in Arabic, the word for doctor is hakīm, which translates to "the wise one." And so I often reflect on how to really understand medicine, you have to also have the wisdom and the discernment to really understand your patient holistically.

For example, there might be a medication that's first line for the treatment of their condition, but we're also thinking about, "Well, what does this patient do for work? Do these side effects influence what they're doing for work?" or, "This patient has a newborn, so we probably shouldn't give a medication that could cause drowsiness or sleepiness."

And so I just try to remind myself it is going to be hard, but that is what's appropriate. I'm going to feel like I don't know anything, and it's because I really know so little, but that's normal for this step. And I think the everyday work ethic and effort will, hopefully, eventually surmount into being skilled at this.

Lilly: That was beautiful, Lena. I love that. I think anyone who tells you they're an expert in their field, I'm always a little . . . the hairs on the back of my head stand up because I'm like, "How can you be an expert in a field that's constantly changing?" We're always learning new things, and there are always new studies coming out. How can we assume that we know everything about this topic? And as soon as we stop questioning things, I think as well we'll start missing things. So that was really great.

Going back to what Jenna was saying, too, it's really interesting because I felt the same way. With neuro, we get senior backup for a few months when we start our next year. But I've been told that second year of neurology residency is the hardest because you're an intern all over again in your actual field, which you haven't practiced since you were a fourth-year medical student.

But then you also are expected to be on nights by yourself and take care of the general service, the stroke service, the consults, the seizures, the ICU, and to be somewhat independent. So that is also very scary.

And I know we'll make it, I know we'll get there, and I think we'll take really good care of patients because we're afraid of missing things and because we want to make sure that the patient is getting the best care that we can give them.

But at the same time, it's kind of mind-boggling that that can happen, that we can go from being internists to becoming ophthalmologists, or neurologists, or radiologists, or whatever else it is that you're pursuing during your prelim year.

I just remember I did a rapid response in the hospital, which is basically where you need a big group of people to emergently come take care of a patient. And my senior was at another rapid response, so I was running my first ever rapid as an intern. Absolutely petrified, but I kind of knew what was going on because I'd been on medicine. I thought the patient had SVT, and we got an EKG, and it looked like SVT.

At that point, my attending walked in, and he was like, "What do you want to do?" And I was like, "Let's do some vagal maneuvers." Didn't work. He was like, "What do you want to do now?" And I was like, "Let's push adenosine." You're just making decisions that you know they're the right decisions but you're just petrified of what's going to happen.

At that point, my attending had come in, and he agreed with everything I was doing. And then I remember later that day, I tried to do a lumbar puncture, which is one of the most basic procedural skills that, as a neurologist I should have, and I totally failed. I was like, "Oh, no. Identity crisis. Am I an internist? Am I a neurologist? What am I?"

I don't know, Shima, have you had any experiences like that? I feel like whenever I see you on medicine, you're always so on top of your patients and you know what's going on. I feel like as an ophthalmologist, you're definitely going to be the same.

Shima: Actually, no, Lilly, I do feel fear. I think it was Jenna that was doing a wellness check in the chat a few days ago, and she asked, "How are you guys doing?" And I just put in, "I'm anxious about starting next year."

But there is a difference. Through my experiences, I've learned that being fearful or anxious isn't necessarily something that you should run away from. You can just see it and feel it, and it's normal. It's a universal feeling. We all face moments that we're unsure of what's ahead and uncomfortable.

From my personal experience, the physical labor, working long hours, that's not the part that scares me the most. It's just not knowing what to do or not knowing what am I going to get into. The unknown, the uncertainty, being uncomfortable, all of this brings me anxiety and fear. And in my experience, it's just okay to feel that. We all feel that, and it's okay to just sit in that and let it be. It will pass.

And when you go into that experience . . . As you said, I'm sure that all of us do have internal desire to be helpful to the patient. Not necessarily a hero because that would bring lots of unnecessary pressure and anxiety again. You don't need to be the hero, you don't need to be the best, but you can do your best, as much as you can, and you'll build skill as you move forward.

As you move forward, skill will come, certainty will come, self-confidence will come, and you will be able to diagnose better and treat better.

And as Lena mentioned, it's just very important to be okay with not knowing and asking questions. It's okay. It's completely okay. For me, that's how I look at it.

But no, it's really stressful for me, too, thinking of next year and again another change. I'm just getting used to this one, and now again everything is going to change and we're going to go into something that is completely new.

Lena: Discomfort is a precursor to wisdom. I think being able to recognize or being aware of your own ignorance is the first step to actually obtaining knowledge and learning. So I think we're all appropriately fearful about facing the unknown, and I think it shows that we care. So, yeah, I just want to reassure my ladies.

Jenna: So beautiful. You are so wise. How lucky am I? These are my co-interns.

Lilly: I know. So much wisdom.

Jenna: In prelim year, I don't know if this happens to you as much, Lilly, but I'm sure Shima and Lena can affirm. In ophthalmology, you hear constantly that, "This isn't going to apply to you." Especially when we're in the ICU, for example. It's like, "Oh, it's the critical care ophthalmologist." And that's fair, because it is true that most of the stuff we did this year probably won't apply to the medicine we practice.

But I think what has really struck me about prelim year is I've learned a lot, and I'm always learning more about what it is to be a doctor, what it is to be someone who cares and listens, and what it is for the patient to feel that they got what they needed out of this interaction, but also for you to feel like you practiced the best medicine possible. I think that always applies no matter what specialty you're practicing.

But it's been really inspiring to me in prelim to just watch attendings or seniors, any doctor, just do that really well. So, yeah, I think that's been a really nice thing for me in prelim.

Thank god I'm never going to talk about AKIs again. I'm so grateful for that. That's something that I think has kept me going when I've felt the burnout of, "Yes, I get it. I'm going to be an ophthalmologist, and this doesn't apply." But also, caring for a patient always applies.

Lilly: That's a really good point, Jenna, because I get the exact same thing. I think in neuro, there's a little more that we can apply. I'm pretty sure neurology came out of internal medicine before it became its own subspecialty, so I think some of it makes sense, especially with patients who have rheumatological diseases or patients who have heart disease or AFib. I think a lot of that overlaps with neurology, and autoimmune diseases, and stroke risk, and all of those things.

So I definitely think that a lot of the stuff I'm learning is applicable, but a lot of it also isn't. And it's hard to really absorb all of the knowledge that attendings want you to, because they're subspecialists that have spent 30-plus years in their field and they know all this minutiae detail about the disease course and the treatments that you'll quite literally never, ever, ever manage. It'll always be a referral to this person.

And I'm enthusiastic to want to learn, but also I only have so much capacity in my brain over the course of a day of learning so many new things that it's hard to figure out what is critical information that I need to know to treat this patient and also optimize my learning without overloading my brain either.

But going off of what Jenna was saying, patients who I've noticed that have had, from how they describe it at least, the most positive experience with their provider or who are really appreciative at the end of a visit . . . Whether it's at the time of their discharge or whether it's in clinic before they go home, I've noticed that a lot of them, and this probably doesn't come as a surprise to anyone, are more appreciative when they feel like they connected with the provider.

The provider took extra time to chat with them about something personal, or they felt like the provider really listened and validated how they felt in genuine way.

Just today in clinic I had a patient who we chatted about his beekeeping for like 10 minutes, and then he chastised me about not being a skier in Utah. And I was like, "That's totally valid. I have failed as a Utahn."

But at the end of his visit, he was so appreciative to the attending and to me, even though we didn't really change any of his medications. We didn't order any expensive tests. A lot of his chronic problems are still there, but we were able to address them and make a plan moving forward. We didn't cure or optimize anything in that visit, but he felt like he was really seen and heard, and was super appreciative.

And then I've had other patients where we've done this crazy vast workup, ordered a million labs, gotten a bunch of tests back, told them, "These are the medications we recommend," and have this goals-oriented meeting with them. And then they leave, and obviously they're overwhelmed. It was a lot of information.

They might have gotten some of their answers, but I don't think it matters how many tests you run or how many medications you give a patient if they don't feel like you're truly listening to them, or that you genuinely care about them.

You know how we typically say things to patients like, "Oh, I tell all my patients that I want them to do X, Y, Z, or that I think it would be helpful for them to do X, Y, Z"? One of these attendings I worked with said, "I tell all the people I care about that I recommend doing X, Y, Z, or that this medication will do this for them." And I just really liked the way he phrased that because then that patient knows that you don't just categorize them as a patient on your list, but it's someone that you care for and that you worry about.

I wonder if that kind of hits on maybe some of the things that Shima was talking about earlier about just how we communicate and show care for our patients or our colleagues. Sometimes I do think western medicine can be a little bit more cold than I feel like other places.

And when my family talks about what their experiences were like . . . My grandpa in Afghanistan was a pharmacist, and he would go to people's homes and see them, and people would bring him baskets of fruit at their visits and stuff and they would call him their uncle and things like that. It was very normal in our culture to feel like your doctor is a respected elder and that they're a part of your family and you care about them.

Whereas I think in the Western culture, we have a little bit more of this professionalism boundary where you don't have that intimacy, and sometimes people look down upon you wanting to treat your patients like they're your family member, which I totally disagree with.

Jenna: But the patients who you build that relationship with are the things that are so meaningful and memorable. I think in intern year, I'm not going to remember pressor management in two years, and I have been taught it at least five times this year. There's no way I'm going to remember it.

But I think the patient who brings you a box of chocolates or whatever . . . Not that patients need to bring us gifts, but you build a connection and it becomes very meaningful to you, and that's what you remember moving forward.

And I agree that sometimes we're kind of too cold. I think the VA actually is a place I've had such a positive experience, in that it's kind of different culturally there. There are less of these professional boundaries.

Lilly: Yeah, that's a really good point. I had a patient who passed away at the VA, and their family hugged me. And when they do the walk when they're going to the morgue, they play . . . Is it "Taps" I think that they play on the intercom and they say, "A vet has fallen"? They walk past when the patient is getting moved, and the family member squeezed my hand and they gave me a hug and we cried together.

I just remember thinking that's such a unique and personal intimate thing that we do for our vets. And I wish we had something similar for our patients at the other hospitals we work at.

Your patient passes away and you call the time of death and you inform the family, and then that's it. Everyone kind of leaves the room and the nurses get them prepared to go to the morgue. It just seems so definite and almost unfinished in a way that I wish there was a way we could honor patients and make it more personal like the VA. That was also something that I agree, Jenna, really, really stood out to me. I liked that they did that.

Shima: I have lots of experience with crying this year. To come back on what you said, Lilly, that is what I was trying to point out too. For me, I can lean forward, I can hug them, I can just soften my voice, sit there, stare in their eyes, but this is not how it's done.

It was interesting for me. I had an ICU patient. It was a very challenging case for me. Not medically. It was just hard for me to accept what the patient was going through. And then whenever I went to go talk to the patient, the parents were there and I would start crying. Eventually, I had to talk to the palliative care team and just talk to my attending, talk to everyone, just wrap my head around it of what am I thinking? What's happening here? How can I be caring and not cry and fall apart myself? We have to be cognizant of this, too.

So for that family, as you said, people are different in VA, for example, from other . . . They might be more embracing of this way compared to other patients, and it's totally fine. That's who we are. That's the beauty of humans. We are different. So that was a huge learning for me, that the language that you express care with can differ based on your patient.

It's okay that you hug one patient, and for another one, you have to be more professional. They might even prefer it like this. And just getting the cues while you're talking to the patient or the family of how they want you to treat them or talk to them, that was the huge learning for me.

For that ICU patient, I was so fearful that my crying was going to be uncomfortable for them. But eventually, it turned out that they did translate it that I really was concerned about their patient.

But for other people . . . for example, I had another one. I could now get some hints of, "Okay, this one, we would need a more straightforward conversation. They want another tone. They want me to deliver the message in a different way."

It's quite interesting. I love when people are different and you can try to meet them where they are. So that's been a great learning for me. But yeah, people are different.

Lena: Medicine is intense. You're dealing with real people, real suffering, real loss. I'll never forget when I was on my ophthalmology elective and somebody had . . . A vein in their eye was blocked, and they were likely going to lose most of their vision in that eye. Losing vision in one eye also affects your depth perception and other things. So they started crying. And honestly, I shed tears too.

I think one of the biggest lessons that I'm learning in medicine is the key isn't to stop feeling those emotions. You want to feel them, but you have to learn how to carry it without letting it break you. I'll never forget that patient who started crying in the office, and I also cried with him.

And I've learned to hold space for those emotions, to not step back from them, but to also use it to fuel my passion in this field, to continue studying it, and to remember this human element of this field. We're not just about fixing bodies or eyes. It's also about healing the human condition and understanding it and feeling for the people around you.

Jenna: That's really beautiful, Lena. To Lilly's point that she shared earlier about, sometimes for us, especially as interns, it's maybe our first time having a patient who we take care of who passes away or has this really tragic thing happen to them. And I think sometimes it can be hard to look around at the attendings and be like, "Hey, why aren't you crying too?"

I had an ICU attending share this really beautiful thing with me that I think about a lot. It's the idea that you have a personal cemetery in your mind of these patients who are really meaningful to you for some reason. Maybe it's the first patient you had that died, or whatever happened to them is really relative to your own life experience.

Everyone's personal cemetery will be different, and that doesn't mean it's bad if a patient had a tragic experience that maybe doesn't make it to your personal cemetery. But it's nice for us to be able to reflect sometimes and go back to those people and think fondly of them. I think it just means we care a lot, and that's what makes us healers and not just physicians.

And I think that's been a beautiful thing about prelim year for me, is I know I've taken care of these patients who I've cried over, who I've cried with, who I will think of for the rest of my career even if it had nothing to do with ophthalmology, but because it was a very beautiful human-to-human experience.

Lilly: And I think acknowledging that in this space amongst us, as we're all friends, but also with our colleagues, is super important too.

When my mom passed away, I would get very easily triggered by a patient who had a similar disease or prognosis as her. I talked about this in my grief episode, but I just remember thinking how odd it was that my colleagues didn't really know how to comfort me in that moment on that rotation or with that patient case.

And then I also remember my first really intense patient loss was in the ICU as well. The ICU is just a scary place to be, I will say. And I remember afterwards my attending was so burnt out because we tried to keep this patient alive for five hours straight and coded them multiple times. It was just a really horrible death.

And afterwards, he was like, "I'm going to sleep." So he went to go lay down, and it was just me and my senior on ICU nights. She also had a patient who had passed away, and she had a new admission, and she was trying to work on her things and check on me. And I just remember sitting there bawling my eyes out at 4:30 in the morning for like 30 minutes.

Then I remember the surgery team was starting to do their suboptimal early morning rounds, and they were coming to see our patients in the ICU. And one of the co-residents who I'd worked with that was taking care of this patient as well came in, and I could just tell from his face that he had seen my note on the patient from the night before that had passed away. He was the one who had admitted her. He just came in, and we both just hugged, and we both just bawled our eyes out at 6:00 in the morning before sign-out.

I just remember he said to me, "If you ever need to talk about this, I'm always here to talk to you about it, because our family and people at home who aren't in medicine don't really get it because they don't have to experience this so intimately of watching someone pass away." And he just humanized the whole situation for me.

And I remember talking to another resident who was a part of another team that was taking care of this patient, and we texted about her for days because it truly haunted us having this loss.

To this day, I still think about her and I still think about that moment. And I feel like it also kind of healed me when I was grieving even earlier on in residency.

I think, as residents, it's hard sometimes to humanize one another because we're so in the motion of getting things done and checking things off and signing our notes and getting out at a reasonable time and things like that, that we forget to humanize one another as well. I just remember that he did that in that moment, and it meant a lot to me.

So I think what we've shared in this space here today is so important to keep in mind, whether you're an intern just like us, a prelim, or you're a resident, or maybe you're an attending who's listening, or you're a medical student or someone who hopes to be a medical student.

Residency is intense, and it can be scary, and it can be stressful, but you also have this immense privilege of being a part of the most intimate moments in people's lives. You're a part of these conversations behind closed doors that a lot of people don't ever get the opportunity to be a part of. And you walk that line between life and death and terminal illness.

You learn a lot and you see a lot, and it makes you really appreciative for the healthy bodies that we have or that we occupy for now. I think it just puts a lot of things into perspective.

I'm just super appreciative that I get to work with such lovely people, and I'm so happy that my residency program brought me a Shima, and a Lena, and a Jenna that I can lean on and that I can see in the hallways and say, "Help," and just look like a deer in headlights with and just feel comfortable saying that I don't know the answer and know that they're not going to judge me for not knowing that.

I hope for everyone who's newly matched that you get to go to a residency program that treats you similarly and that gives you people like these amazing human beings. And I'm so grateful that you all took time in your busy schedules to chat with me and chat with "Bundles."

I just think it's really important to know what you're getting into, even though you never really will know. But if you're an aspiring prelim, you'll get through it, you'll learn a lot, and you'll get that much closer to your dream.

I just want to thank you all for listening to this week's episode. We're super excited to be able to have these conversations and give you guys a little bit more exposure into what residency life is like, especially as a lot of our listeners are starting to enter that part of their lives.

And in the meantime, until our next episode comes back, you guys can find us at our website, bundleofhers.com, as well as our Instagram, @bundleofhers.

And if you haven't already, make sure that you subscribe and leave us a comment and chat with us a little bit more if you've had any experiences in residency or things you're afraid of so we can keep these conversations going. Bye, guys.