9. The Duck
Learning about staying afloat and the illusion of control
One Wednesday morning in June 1993, we held one final Grand Rounds–usually a weekly gathering of the entire Department of Pediatrics where a speaker gives an expert-level address about a timely and interesting topic in the field of pediatrics. However, as was tradition under Dr. Oski’s leadership, we dedicated one such grand rounds in June to the senior residents–a meeting we affectionately called the “Love Fest,” where these most senior trainees simultaneously roasted and thanked the faculty and the more junior trainees who were also training to become pediatricians. The jokes were plentiful and sharp in a fun-loving way.
They had every reason to celebrate. Completing a pediatric residency is the culmination of 7 or more years of education and training beyond college, including 4 years of medical school and 3 years of training to become a pediatrician. Some medical students spend an additional 4 years earning a PhD if they want to focus on research in their careers. The training process is called a residency. First-year residents are called interns—new physicians learning to care for patients under close supervision—followed by assistant residents, then senior assistant residents, each layer gaining more responsibility with less supervision. In pediatrics, there is only one year as an assistant resident, while in surgery, there may be many more, depending on the type of surgeon one wants to be. A chief resident is a final year of residency for a select few of residents. The chief resident is responsible for supervising and managing everyone below: building schedules, mediating conflict, absorbing crises, and keeping the system running–all while seeing patients to some degree. Chief residents are not supervised, per se, but they are observed by other departmental faculty and staff, who provide letters of recommendation to help launch their careers. It was a role with authority downward but vulnerability upward, responsibility in every direction, and protection in very few—a position analogous to an adult duck in the water whose calm demeanor was steady, despite any turbulence in the water.
As it was, I was the chief resident for this group of graduating residents. I was their taskmaster, teacher, and supervisor. I’m sure there were more than a few barbs pointed in my direction, but I cannot recall a single one.
Shortly after this love fest commemorating my chief resident year, there was a more “official” celebration. Names were called, applause followed, and certificates exchanged. Department leaders offered remarks about transformation, the kind of growth that makes you proud and a little sad at the same time. I’m sure I said something self-deprecating that sounded like humor.
After the formal send-off, the room relaxed. Conversations loosened. Families filled the rows, parents leaning forward with cameras already raised, children darting between chairs like the rules didn’t apply to them yet. One by one, my senior residents wrapped their arms around me, thanking me for my steadiness, for my support, for getting them through.
I nodded at the right moments, laughed when a joke landed, returned congratulations that sounded sincere even to my own ears. People lingered. I was pulled into photos, hugged tightly, thanked again. I thanked them back, carefully, generously.
And yet, even as the celebration swelled around me, I felt oddly separated from it and not relieved. Not triumphant. Not even tired in the satisfying way that follows a challenging year. Instead, I was tense and watchful, aware that my internal perception of the year did not match what was being celebrated, and hopeful that no one in the room would notice my conflicting emotions or my reaction to what I perceived was a disappointing performance in the role.
I remember being honored by the invitation to serve as chief resident. Being asked felt like recognition, confirmation that the long hours, the rigor, and the emotional labor of residency had added up to something visible. I was also doubly honored to be named chief editor of the thirteenth edition of the Harriet Lane Handbook, a book that residents across the country carry in their pockets and trust in their patient care decisions. My term as chief resident was set for 1992-1993, after I completed three years as a resident, followed by a 2-year fellowship in medical informatics at Stanford.
At the outset, the role felt like recognition and opportunity: a chance to contribute meaningfully while learning about leadership from mentors I respected, standing at the threshold of what came next. For me, it was a validation that I belonged. I was a good physician. I loved what I did. I wasn’t an imposter.
I knew there would be hard work. I would have to be that duck on turbulent water, smooth on the surface, while beneath it, my feet paddled incessantly to stay afloat. I said “see you soon” to Dr. Oski before proudly heading off to the sunshine and brown foothills of Palo Alto.
As I entered my final year at Stanford, I did research by day and saw patients at Kaiser Redwood City by night. During my first year and second summer there, I’d built a life that rekindled my joie de vive after an exhausting residency. Student neighbors biked to work with me past eucalyptus-lined entrances. Tuesday-night community chorale nourished my soul. Tennis a few times a week got me back in shape. My pet parrot, a small, midnight-blue Pionus with streaks of red and yellow around his eyes and a squawk loud enough to express his feelings, became my roommate. Most evenings, I called my girlfriend, a Baltimore nurse who became my fiancée near the end of my first year in California. I was learning a ton and doing all the things I loved.
One day that fall, a note arrived from the publisher of the Harriet Lane Handbook. Editing would begin in a month. Chapters needed to be assigned to the residents who would update and revise them during their senior year. I’d been through the process as a senior editing a chapter of the twelfth edition, so I understood the rhythm and the stakes.
That note was my first tangible reminder that the chief year was no longer theoretical.
Over dinner, I pulled a manila folder from my desk and labeled it simply “LANE.” I tore a fresh yellow sheet from my steno pad and went looking for the list of soon-to-be senior residents. It took me longer than it should have. I found an old match list from two years earlier, and I carefully wrote down the names of the almost two dozen people who I would soon supervise in their new role as senior residents and as co-authors of the Harriet Lane Handbook.
As I sat eating chicken teriyaki, a problem became obvious. I didn’t know these residents at all. My being away at Stanford for two years meant that they didn’t start their residency until I left for California. I didn’t know who was thriving and who might need help as a senior resident. In other words, I didn’t know them well enough, in truth, to give them what they needed to succeed. I knew as much about which chapter each of them would want to do as the Titanic knew about the iceberg waiting just beyond the fog.
That was the first sign.
A call to Hopkins and a few mail exchanges later, I fixed what I could from California. I introduced myself, laid out the Lane timeline, asked for their top three chapter preferences, and sent the information to the publisher. It was neat. It was efficient. It let me return to Stanford life with the pleasant illusion that I could keep both worlds running in parallel.
Not long after, I was deep into preparation for my master’s qualifying exam, an arduous task of memorizing facts about biomedical informatics luminaries, when the lead residency administrator called to remind me that the schedule for the next academic year was due. The new intern list had been published. Though I recognized a few names from my resident days, most were new to me.
I pictured them in fresh white coats, nerves humming, thrilled and terrified to be allowed to write prescriptions without a cosignature from a “real doctor.” I remembered that feeling. The part of me that liked people, that liked teaching, that liked providing steady reassurance, was genuinely eager to help.
And then, as if to complete the trifecta of simultaneous obligations, wedding planning moved from fun to logistics.
In between studying and finishing my research, my fiancé and I slogged through what felt like a prolonged triage exercise: deciding which of the people we loved but weren’t biologically related might survive the guest list. At the same time, our parents assembled their own non-negotiable “keeping the peace” roster. That was when I learned the difference between getting married and having a wedding. One was a commitment. The other was a stage production, complete with lighting, cues, and two families who would never have chosen the same dinner table under any other circumstances.
Luckily, having just taken courses in fields that dealt with managing constraints, I figured out a way to solve this problem. I first sent invitations to people I cared about but didn’t expect to attend, counting on polite declines to tell me how many seats I truly had. Once the returns came in, I’d know how much room remained to fill.
It was practical engineering at its best, and for a moment, I felt like another major checkbox was done…until the pastor who had agreed to marry us backed out because I refused to convert to his Christian subgroup! The church was kind but firm: without him, the ceremony could not happen there.
It was the production equivalent of losing a principal actor and the theater in the same phone call, only months from opening night. The clock, which had been politely ticking in the wings, stepped into the spotlight.
What followed was a blur of calls, negotiations, and hours siphoned away from studying, from research, from building the resident schedule, hours that still had to be reclaimed around my clinical shifts. I told myself it was temporary, manageable, solvable.
But the feeling was more specific than stress. It was the sensation of trying to remove cookies from the oven while still chewy and yummy, while someone keeps distracting you to help them solve a crossword puzzle clue, “Hey, what’s a 10-letter word for conflict where there should be harmony?”
I stayed in resident mode anyway. Box checked; on to the next item.
I returned to the residency schedule as if it were a clean grid: rows as people, columns as months, each cell a rotation. I built versions around vacation preferences, staggering challenging with more effortless rotations, keeping couples together when possible, and more. This looked, on paper, like a solvable problem.
I mailed the schedule back east and returned to California living.
Two weeks later, schedule cracks appeared. It began with a call from the current chief resident, Sue. “Hey Kevin. I know you’re busy trying to finish your degree requirements, but we have a problem with the schedule.” I listened and tried to keep my voice light, the way I spoke to residents when they brought me a complicated patient and asked what to do next. Sue started with changes that were not optional: a new adolescent medicine rotation for all second-years. Then another: expanded coverage at St. Agnes Hospital, with residents to be integrated and new vacation requests to collect. The details were manageable individually. The problem was what they did collectively. Each change rippled. The grid became a Rubik’s cube, and I couldn’t solve it using a spreadsheet anymore. It represented people’s rest, people’s mental health, people’s limits, people’s learning, people’s families. Spacing mattered. Sequencing mattered. What worked on paper could be brutal in life.
It took longer than I wanted to admit for me to get it into a form that worked. Box checked again.
By then, I had only days to focus on my oral exam.
The oral exam was exactly as taxing as we’d been warned it would be. At 10:00 a.m. I was invited into a conference room where six faculty sat around a table, and I took the head seat like a defendant in a polite trial. The chalkboards were clean. I was handed a short piece of yellow chalk and told there was more where that came from.
For an hour I answered questions using chalk and my voice, then follow-up questions, then follow-ups to the follow-ups. By the end, I was certain I had said a few things that were wrong, incomplete, or indefensible. I thanked the group, walked outside, and sat on a bench.
The tears came quickly. Not a graceful cry–it was unadulterated panic and despair.
A few minutes later the door opened. One of the faculty called my name. I wiped my face with my sleeve and stood up like I had done something improper. As he came into focus, I saw, his outstretched hand of congratulations. I had passed with flying colors.
I was so relieved I couldn’t stop staring at him. Tears of despair were replaced by tears of relief. Another major box checked!
After a few days of decompression and a month to complete my thesis, I attended parties, thanked people who had helped me, and began the logistical process of leaving California. I started to feel excited about returning to Hopkins. I imagined meeting the residents, learning who they were, helping them through the predictable crises and the surprising ones. I imagined myself as one of the chief residents I had admired.
I thought I was ready.
My fiancée met me at the airport. We hugged and kissed the way we always did, the kind of embrace that makes you believe you can handle what comes next. She drove me home, where my parents met us at the door, eager for details about Stanford and thrilled to have me back. My mother had a bottomless list of updates about people I had not seen in years. I feigned interest, already aware that the wedding would rearrange the center of my life, whether anyone admitted it or not.
“Oh, by the way,” she said casually, “someone named Dr. McMillan called and asked for you.”
Dr. McMillan was the new head of the residency program, a national figure in pediatrics. I didn’t know her, but she was about to be my boss. I assumed there was paperwork. A meeting. Something routine. But my experiences to date had me wary of potentially bad news.
I called her immediately.
By the time the call ended, my body felt as if I had just walked out of the oral exam again.
The schedule had to be revised, she said. The anticipated number of residents from St. Agnes had fallen. The adolescent medicine requirement was still non-negotiable. And then she added what Sue had not: two second-year residents needed accommodations for health reasons. One could not stand for prolonged periods during the first months of the year due to a back issue. Another required limitation on night call due to a recent mental health crisis. It was all said professionally. Kindly. As if it were information being handed over at sign-out. But I could do the math. The schedule I had barely made work from California was now impossible without extracting a toll on someone.
And that someone, I soon realized, would be everyone.
I began working the problem, but was both distracted by the wedding planning and stymied by the new scheduling constraints. Every fix created a new misalignment. Helping one resident meant increasing the burden on another. In my own mind, I had become an equal-opportunity disappointer. Everyone was going to be frustrated with me—and worse, I was going to be disappointed in myself for what I’d done to these incredible people.
I went upstairs to my old bedroom, the place where I used to hide when junior high felt too loud. My appetite disappeared. I told everyone I was fine. I moved through the house as if I were trying not to take up space.
What made it worse was the moral dissonance. I wanted the year to be good for them. I wanted residents to feel supported. I wanted to be the kind of leader who made hard work feel purposeful. Instead, I was about to hand them a “successful” schedule that would test their bodies and their spirits. Incoming seniors already burdened with Lane chapter edits would carry more shifts in the busiest units. Others would be placed in back-to-back rotations we all knew were punishing. And I would be the face attached to all of it.
The beating I gave myself was constant and private. I was the only chief resident, and as far as I knew, no other chief residents needed help with the schedule. (Of course, how could I know that really?) I knew that Sue, the current chief resident, understood what was needed, so I asked her for help.
At the time, it felt like a practical decision, a way to keep the whole system from unraveling. What I did not understand then was how exposed it made me feel. I had come to believe that competence meant containment, that asking for help signaled a personal failing rather than a structural one. Reaching out did not feel collaborative. It felt like confirmation that I was not as capable as I had thought.
Sue stepped in and solved the Rubik’s cube. A demanding schedule went out; the immediate crisis was over. And with it, so too did my contingency for any new issues. From the outside, nothing appeared broken. But something in me frayed.
The year continued. By most measures, it went well. We submitted the new edition of the Harriet Lane Handbook. The residents endured a challenging schedule. Accommodations were made. Coverage gaps were filled. No one was harmed.
Those outcomes should have reassured me. Instead, they reinforced a quieter conclusion: the work succeeded despite my inadequacy. I began treating leadership responsibilities like yet another checklist, keeping my head low so as not to be found out as a fraud, and withdrawing the parts of myself that once felt confident and curious.
After about six months, I briefly thought about resurfacing. We hosted a guest speaker from the Indian Health Service who described conditions in the Navajo Nation and the barriers posed by distance, staffing shortages, and limited access to specialists.
My informatics training stirred. The question that formed in my mind wasn’t naïve; it was the kind of question people asked when they were trying to help by instilling new knowledge.
From my seat beside Drs. Oski and McMillan, in a room that had gone quiet after his talk, I raised my hand and asked whether telemedicine had been considered as a way to extend specialty care.
His response was immediate. “Um…not really. We already have telephones.”
I knew the difference, and he obviously didn’t. I could have helped the uninitiated understand that telemedicine provided a bidirectional video feed, an ability to observe movements and hear speaking challenges–in short, it was as close to an in-person visit as one could get without breathing the same air. Instead, a pause settled over the room. The air felt thick; no one spoke.
My mind generated an audience response that was loud and cruel: You idiot. You don’t belong in the front row. I pulled inward, a reflex I had practiced since childhood whenever there was a threat, even when the threat was ambiguous or internal. And once I pulled inward, I stayed there. I was done asking questions at Grand Rounds. In my mind, I had nothing to gain and everything to lose, even when I was asking something important. “Maybe,” I thought, “I’ll just meet with speakers privately.” I saw no need to convey my thoughts to the rest of the public who might or might not appreciate them.
Shortly after this love fest of my chief resident year, we hosted a celebration. Names were called, applause followed, and certificates exchanged. Department leaders offered remarks about transformation, the kind of growth that makes you proud and a little sad at the same time. I’m sure I said something self-deprecating that sounded like humor.
The attention then turned to me. Speeches were made. Kind words were offered. Drs. Oski and McMillan presented me with two gifts: a desktop clock and a history of medicine book. There was a lengthy applause, pictures, hugs, smiles, and thanks.
And then it was over.
In fact, we all had every reason to celebrate a year had gone well. The Harriet Lane Handbook was published. The residents survived. The schedule held. I had survived. But there I stood, holding the clock, its weight heavier than it should have been. Gratitude should have landed somewhere in me, and it did as I looked on at the graduating residents who seemed happy and well-prepared to embark on their careers or possibly to pursue additional training in specialties like hematology, cardiology, or emergency medicine. But as for myself, all I felt was the year ticking through my body: late schedule revisions, compromises, a constant awareness of being ruled by time rather than leading within it.
My mind insisted the “gifts” carried a subtle message about my subpar performance. It never occurred to me in that moment that the decorative clock might simply be a clock. That the history of medicine book might merely be a nice book. That the brevity of the moment reflected institutional habit rather than someone’s barometer of my performance. I had become a duck in a lake of alligators, unable to fly to safety and therefore hypervigilant as a survival instinct.
By the end of the year, I no longer felt like someone being shaped by a leadership opportunity; rather, I felt like that duck must feel if its webbed foot was tattered and torn–struggling not to be a meal for some predator. The confidence I had finally earned, the belief that I belonged, that I was capable, that I was no longer auditioning, had been lost–at least in my head.
Although my leadership skills might evolve with more experience, I didn’t want to try again. I hadn’t yet identified the language for what the year had taken from me. I only knew I felt smaller in the eyes that mattered most–my own–and that I was not destined for leadership and the lack of control that comes with it. I would paddle comfortably on a calm stream, but not take on the Class 6 rapids.