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There’s a moment in training that almost everyone experiences, but very few people talk about. It’s the moment where you look around and feel like everyone else has figured it out. They seem faster, more confident, more decisive. They present smoothly, make plans quickly, and move through the department in a way that feels just out of reach. And quietly, almost without realizing it, you start to wonder if you’re behind.
I see this all the time in the Emergency Department. An intern hesitates before placing orders. A second-year double-checks decisions they actually already know. A senior resident, someone who is objectively strong, still looks over their shoulder, just to make sure they didn’t miss something. And underneath all of it is the same question: Why does this feel harder for me than it seems for everyone else?
But here’s the truth: you’re not behind. You’re just early in the process.
Emergency medicine is deceptive in that way. From the outside, it looks like a series of rapid decisions- quick diagnoses, confident plans, decisive actions. It looks like people just know what to do. What you don’t see is the cognitive work underneath. The pattern recognition that takes years to build. The tolerance for uncertainty that has to be practiced. The thousands of small decisions that slowly become automatic.
When you’re early in training, none of that is automatic yet. So everything feels harder, because it is. You are doing, consciously, what others are doing subconsciously. You’re thinking through every step, double-checking your reasoning, questioning your decisions, and trying to balance thoroughness with efficiency. That isn’t a flaw in your ability. That is the work of becoming.
There’s a cognitive bias we sometimes reference, the Dunning-Kruger effect. Early on, confidence can be high before true complexity is understood. Then, as knowledge grows, confidence often dips, because now you see what you didn’t know before. In medicine, that dip can feel uncomfortable. It can feel like you’re getting worse, not better. But in reality, it’s the opposite. That discomfort is a signal that your understanding is deepening.
The moment you begin to recognize complexity, to question yourself, to sit in uncertainty, that’s when real learning begins. That’s when you move beyond memorization and into true clinical reasoning. You’re no longer just following algorithms; you’re learning how to think.
I often tell residents that I don’t worry about the ones who question themselves, I worry about the ones who don’t. Because uncertainty, when approached thoughtfully, is not a weakness. It’s awareness. And awareness is what keeps patients safe. The goal is not to eliminate that feeling overnight. It’s to learn how to function within it.
Over time, something shifts. The pauses get shorter. The decisions get faster. The uncertainty doesn’t disappear, but it becomes quieter, more manageable. You begin to recognize patterns more easily. You start to trust your instincts, not because you’ve eliminated doubt, but because you’ve learned how to work alongside it.
And then one day, without realizing it, you become the person someone else is watching, the one who seems calm, confident, and capable. The one who appears to have it all figured out. But if you’re honest, you’ll know that’s not quite true. You haven’t eliminated uncertainty. You’ve just learned how to navigate it.
That is the real skill. Not perfection. Not speed. Not even confidence in the way we often define it. It’s the ability to keep moving forward (thoughtfully and intentionally) even when things feel unclear.
So if you’re in that phase right now, where everything feels slower, heavier, and harder than it should, it’s not because you’re behind. It’s because you’re still doing the work out loud. And that work- the visible, effortful, uncomfortable part—is exactly what eventually becomes invisible.
You’re not behind. You’re exactly where you’re supposed to be.
