The question of when medical students, residents and fellows (doctors completing specialty training) and practicing clinicians first felt they really were doctors has always intrigued me. Why? Because I taught medical students and occasionally residents and fellows at the University of North Dakota, and sometimes practicing doctors. You might be interested in this question because its answers bear on what doctors expect of themselves. In addition, comparing answers offered by people at different points in their medical careers provided insights into how they understood what they do for patients.

For example, a colleague, Bob, said, “I know exactly when I knew I was a doctor -- the first Halloween after med school. I was in the Emergency Room, and it was that there was nothing patients could throw at me that I couldn’t handle.”

This meant he knew when to give the patient two aspirin and tell her to call her doctor in the morning, to suture the wound, write a prescription, order an X-ray or test, call a specialist -- all to figure out what was happening to the patient.

Bob completed his internal medicine residency, did subspecialty training in gastroenterology, and continued learning to care for patients across a progressively wider range of problems in the ER and the internal medicine clinic. How did this happen? Bob quickly diagnosed patient problems he recognized, and figured out what needed to be done when patients’ needs were unclear. And so Bob indeed felt he was a physician.

When I asked the same question of medical students, I learned some third-year students claimed they were really doctors after only two years of largely classroom experience. How could this be?

First, they misinterpreted cues from their environment. In Bob’s case, the cues came from what he learned diagnosing and treating patients with his supervisors’ confirmation that he’d done fine. In the medical students’ cases, however, cues came from patients who (though treated by others on the medical team) called them “doctor.” The patients, of course, didn’t know any other term to use.

Despite this, the most dramatic reason I heard for a student’s believing he was a doctor came from another third-year student, Jim.

Jim asked to be assigned to an older charity hospital in New Orleans.

One morning, Jim showed up to learn the resident he’d been working for was sick, and the physician responsible for the ward where he worked was unavailable. He was, however, approached by a nurse declaring a patient was breathing in a labored, noisy manner and needed help.

His help? Despite his inexperience, and seeing the patient only briefly, he recognized that her problem was serious, that if she didn’t receive immediate care, she’d die. And he couldn’t imagine what her problem was, never mind how to treat it.

Indeed, the only thing Jim knew was to find a physician. Fast.

He found one a floor down and told him of the patient. The doctor simply said, “Let’s go” and headed upstairs, Jim close behind.

On reaching the woman, the doctor announced she suffered from a pneumothorax (a hole in her lung and air was leaking through it into the space between her damaged lung and her chest wall). And air leaking from her lung into the space between the lung and her chest wall caused her lung to collapse and she could no longer absorb oxygen into her blood to be circulated. It also meant carbon dioxide in her blood could not be released into her lung and exhaled. These things, left unattended, meant the woman would suffocate.

“What do you want to do?” Jim asked -- to which the doctor responded by asking Jim to begin evacuating the misplaced air from the patient’s chest cavity so she could resume breathing normally…and so live.

“I don’t know what to do,” Jim declared, frightened.

“Well,” the doctor said, “you were smart enough to recognize help was needed, and that tells me you’re smart enough handle what needs to be done” adding immediately, “I’ll tell you what that is.”

He disappeared returning shortly with syringes and needles needed to enter the patient’s chest cavity as well as plastic tubing and equipment for sucking air from where it shouldn’t be allowing oxygen to resume being absorbed in the lung and carbon dioxide breathed out. The physician’s demeanor reassured Jim that he could, indeed, do what was required.

Jim shortly had two needle tipped syringes in place, the tubing connecting the syringes to the running suction pumps. Almost immediately, the patient’s breathing was more normal and her lip color changed from death-anticipating blue to healthy pink. The doctor then called for additional equipment to monitor the patient as she continued recovering.

As Jim and the doctor were setting up the monitoring equipment, the woman’s lips again started turning blue and her breathing again became labored. Both Jim and the physician realized her other lung was collapsing. This time, however, Jim needed neither instruction nor encouragement. He moved to the other side of the bed, put in new needle-tipped syringes, and ran tubing from them to the suction pumps and so relieved the patient’s distress.

The two men again waited as the patient’s condition stabilized before the physician again noted Jim’s success, Jim thanked the doctor for his guidance and support, and they both began documenting the patient’s problems and their resolution.

The whole episode left Jim feeling just as Bob described. In Jim’s case, however, the environmental cues he interpreted included the doctor’s comments on his recognizing a need for help, seeking it out, and learning and then doing what was needed to address his patient’s problems. Like Bob, the environmental clues came from a physician’s observations, and Jim’s learning concerned what was going on and then what to do in meeting the patient’s needs.

That’s why Jim did, indeed, felt like a doctor despite the fact that he was almost two years away from medical school graduation. It is also why, his medical training now complete, I’d be pleased to have him caring for my grandkids.

Hank Slotnick is a retired UND professor who, with his wife, winters in Pima, Ariz., and summers in Debs.