Becoming a Physician: The Evolution of a Career
Who you are depends on where you are.
Think of the beginning of a medical career as the time that we enter medi- cal school, rather than the moment when the first paycheck as a practicing physician, teacher, or researcher arrives. Many transitions occur: from stu- dent to practitioner and teacher, from less experienced to more experi- enced, from novice to veteran, from smaller income to larger, from one place to another. Changes come in age, expectations, values, and character and in the profession and the world at large. New diseases are identified, and the technology and views of illness evolve. But for the most part, the catalogue of diseases and problems a physician deals with remains the same, and the human dimension is timeless.
One of my colleagues, whom I have known since he was an intern, told me one day, “I’m turning 50 and I see things differently now. At 40, I was building a practice and doing lots of surgery because that’s what I do. Now I’m a physician first, who also does surgery. I had a family conference about a lady who’s had eight surgical procedures over the last month. Her daugh- ter said, ‘Pa, since mother’s had her stroke, she hasn’t had a happy day. What are we doing all this for?’” Older and wiser, the surgeon saw questions and issues that he had not seen as a younger physician. Indeed, how we look at our practice can skew how we deal with issues and conduct ourselves, how happy we are, how likely we are to become disenchanted, and how well we deal with change. The evolution of our career takes place in paral- lel with the evolution of our personal life, its successes and losses, the ma- turing of relationships, the renewal of old interests and the development of new ones. We miss a lot without growth.
None of these scenarios approximates what really happens:
• You decide to become a doctor. You go to medical school and learn what you have to. You become a doctor. You start practice alone or join an already estab- lished office and remain there for the duration of your professional career. You practice for thirty to forty years. You cease practicing. End of story.
• You are a sensitive, altruistic person. You become a doctor. End of story.
• You cannot stand the sight of blood. You cannot deal with a patient with an in- curable illness. You cannot deal with death. You decide to become a doctor, and you immediately learn to deal with all these matters. End of story.
Just as the brief history that began this book, the one about the physician with heart disease who had coronary bypass surgery, does not do justice to his real story, neither does any one of these “histories” adequately describe the path with many detours that a medical career takes. We learn skills, to be sure, but we also refine goals and values. We change homes, towns, and practice situations. In the course of a career, we enhance our knowledge, become wiser in how we deal with patients, and become more realistic in what we can do and what we can predict. We make countless decisions out- side of the patient-oriented ones—about how we let our career affect our personal lives and about what, of all the pressing matters, is especially im- portant.
I like what Chaim Potok wrote in In The Beginning. His first-person pro- tagonist is a teacher.
All beginnings are hard.
I can remember hearing my mother murmur those words while I lay in bed with fever. “Children are often sick, darling. That’s the way it is with children. All be- ginnings are hard. You’ll be all right soon.”
I remember bursting into tears one evening because a passage of Bible commen- tary had proved too difficult for me to understand. I was about nine years old at the time. “You want to understand everything immediately?” my father said. “Just like that? You only began to study this commentary last week. All beginnings are hard. You have to work at the job of studying. Go over it again and again.”
The man who later guided me in my studies would welcome me warmly into his apartment and, when we sat at his desk, say to me in his gentle voice, “Be pa- tient. . . . You cannot swallow all the world at one time.”
I say it to myself today when I stand before a new class at the beginning of a school year or am about to start a new book or research paper: All beginnings are hard…. And sometimes I add what I have learned on my own: “Especially a begin- ning that you make by yourself. That’s the hardest beginning of all.”1
The first surgery I ever witnessed was a ritual circumcision. I was 20, a se- nior in college, and had already been accepted to medical school. I almost fainted. The sight of blood does not bother me anymore. I grew. I evolved. I got handy at dealing with these things, but not overnight. How we evolve as physicians—our initial choice to become a physician and then what kind of a physician and human being we will become—depends on at least three factors: personal experience, role models, and the communities to which we belong. Though they vary in influence at any given time, ulti- mately we derive our values and our character from all of them.
• Personal experience. Just like patients, physicians have things going on in their lives—illness, concerns regarding parents, children, and income, and the frus- trations of living a complex adult life. A good doctor handles them in ways that do not intrude on interactions with patients, but she can also use the insights and wisdom gained from these experiences in dealing with patients. And so in their first assignment in my seminar, I ask students to reflect on an illness that they or a family member experienced, what it was like for them, what were the best and worst parts of the experience, and how they handled it. Finally I ask them, “What do you learn from reflecting on all of this?”
• Models. My formative view of a physician came from our family doctor. I ask stu- dents, “Who are your models?” They talk about parents, relatives, friends, phy- sicians, and teachers and the qualities that they wish to emulate. Over time, we add to our list of models.
• Communities. As we identify more closely with a community, we begin to reflect the community’s values. Nationality, religion, and socioeconomic group are among the more commonly defined communities, but there are others. The neighborhood, the town or city, the specific place of worship, the school, the community of physicians, medical students, or residents, and others are all sources of values.
THE EDUCATION OF A PHYSICIAN
Learning about the human side of medicine never ceases, nor does it have a precise beginning. But let us define the parts of a physician’s educa- tion as what precedes medical school, then medical school and residency training, and what follows.
Before Medical School
These are some of the lessons I learned from reflecting on my undergrad- uate years.
Of organic chemistry and embryology, I remember benzene rings, the
ortho-, para- and meta- positions, that “ontology recapitulates phylogeny,” and something about the embryonic aortic arches and their relation to the persistence after birth of a patent ductus arteriosis, a congenital abnormal- ity of the blood vessel architecture near the heart. Though I did not retain much else, I learned how to organize information and learn in a systematic way. I learned that the more I learned, the easier it was to retain it, because I had an increasingly more refined structure to which to connect the new in- formation.
I do not remember much from my two years of philosophy except that they were about “meaning.” Now I have an interest in spirituality, which some define as finding meaning in life’s events. I often ask patients, “What does this illness mean to you?” and that question often leads to a discussion of their fears. Philosophy was also about values. Now, as a physician, I know the importance of values and that if we do not have a strong sense of values at the beginning of our career, then it is harder to learn and adopt those val- ues somewhere in midcareer.
I do not recall much detail from my general psychology course. But now I am fascinated by the psychology of groups—of organizations, meetings, medicine, and communities. Sometimes I ask patients, “Who is your com- munity?” in order to find out to whom they turn to for support in times of need. From my psychology course, I also remember this exercise: Connect all nine dots with four straight lines without lifting the pencil from the pa- per (Figure 18.1). The imaginary square around the dots does not define the limits of the solution: Go outside the square to perform the task (Figure
18.2). As a teacher, I use this exercise as a way to teach that good physicians need to think originally, to go beyond the obvious borders of a problem, to look at things in yet one more way in order to consider all the options to solving a problem.
I hardly remember anything from my world history course. I do remem-ber that World War I did not begin, as I learned in high school, because someone assassinated the archduke of Austria. The story began much ear- lier, as nations laid plans and formed alliances for the conquest of Europe. It is like that in medicine. Patients may begin the story of their illness where they think it began. Our task is to explore the story more completely, for it may have begun long before. Developing the patient’s story in this way pro-
vides more insight into the illness and the patient’s life, and it may influ- ence the process of care and the outcome.
I started to study German as a freshman because I thought that German was the “language of science.” I continued these studies because of the warm relationship I developed with my teacher of four years. Today, to de- velop the inquiry about the doctor-patient relationship, I often ask my students, “How is the doctor-patient relationship like the teacher-stu- dent relationship?” From my German teacher, I learned the importance of caring about a student—and saying so. Not a bad model for a teacher and a physician.
I have used the language with German-speaking patients, and because of my German training, I was able to hone my facility with Yiddish, a similar language and the language of Eastern European Jews. I had many opportu- nities to use it in speaking with Russian Jewish immigrants who became my patients. My interest in using their language enhanced our relationship. It is a good metaphor for the doctor-patient relationship: In order for the rela- tionship to be a good one, the doctor needs to speak the patient’s language, not vice versa.
As a senior I took a course in linguistics with only three other students. For one of our assignments, we were given a text of Swahili and the transla- tion of a few words and asked to construct a Swahili grammar. Suddenly a light went on! I could do the task pretty comprehensively, evolving rule after rule, testing the newly evolved rule with another part of the text. For me, this was a major step in deductive and creative reasoning, the result of an active partnership with my teacher. Deductive and creative reasoning and partner- ship between the patient and the doctor are a large part of medicine.
In my freshman English seminar, I learned to write and to express myself clearly. To do that, I needed to organize and clarify my thoughts, critique and edit myself, and internalize what my professor did for me so that I could become my own teacher. In four years of required public speaking courses,
I learned to make my presentation more interesting; that skill comple- mented my ability to write. As a physician and teacher, I choose my words carefully. I ask myself, “What works and what doesn’t? Did my patient or my student hear it as I meant it?” When I was in practice, I “edited” my pa- tients’ stories, taking their spontaneous narratives and turning them into cohesive wholes without altering the sense and the facts, so that I could draw valid conclusions and communicate clearly with my colleagues. Now students are my audience, and I tell them that part of the way I evaluate them is by their ability to write and speak. Physicians need to think, speak, and write clearly.
But I did not learn much about choosing a career in college. I never looked carefully at myself, my values and choices, how I would integrate my personal and my professional life, and what it was really like to be a physi- cian. Though I have never regretted my choice of professions, if I had known better, I would have chosen more deliberately. I try to help my un- dergraduate students make an informed choice.
Now, in retrospect, I appreciate my undergraduate years more and more, and I know:
• An undergraduate education is a gem, a once-in-a-lifetime opportunity to pre- pare, in the broadest sense, for a career; to look at our abilities and aptitudes, pri- orities, and personality; and to define and refine our values. After all, among the most important choices in life is that of a career and life’s work.
• There are seeds of insight being planted in each of the courses undergraduates take. Their task as perpetual students is to recognize these insights. Students
need not be concerned if they do not see them yet, for they may become appar- ent only years later. One simply needs an open, inquiring mind.
• As teachers, it is our special task to transmit not simply information but tech- niques for learning and how to inquire. We need to help students frame or reframe their questions. We need to keep as open and inquiring as we ask our students to be. We need to know how to be good models. And we need to learn from our students.
The years before medical school provide many lessons and insights about the human side of medicine as well as endless opportunities to learn and reflect. People sensitive to the human issues emerge from different paths: science majors and those majoring in music, engineering students and those expert in history, people right out of college and those starting medicine one or a few years later, often as a second career. All have in com- mon intellectual capacity and curiosity, a commitment to lifelong learning, and the human qualities.
Medical School and Residency
How do we preserve the sensitivity to the human side of medicine that most bring to medical school? How do we maintain the values we have de- fined from our experience, models, and community? If medical students be- gin with all this wisdom and sensitivity, what happens to it? During medical school and residency, we learn skills in diagnosis, treatment, and prognosis and we refine those skills—at a minimum. What about the human side?
No small part of a career in medicine are the years in medical school and residency. If our professional life is the sum of four years of medical school, three to six years or more of residency training, and thirty years of practice, then medical school and residency constitute up to a fourth of our profes- sional life; and so prospective doctors ought to know what it is like. I have heard descriptions ranging from “exhilarating and wonderful” to “dehu- manizing and awful.” What makes it different for each person has to do with preparation, clarity of purpose, wisdom in parsing out our life to school and the rest of our life, how we deal with stress, and how well we learn.
Choosing the right medical school and residency helps us preserve our humanity. Students often choose on the basis of quality and cost, but be- yond those factors, they often consider:
• The “culture” of the place, what it is like to be there. Is it an atmosphere that supports its students in their process of learning, recognizes them as individuals,
models the relationship with patients, addresses values, and endorses and teaches the biopsychosocial model of medicine? Does it teach what it is like to be a professional? What are the students like? Is the atmosphere collegial or “cut-throat?” Is there an esprit de corps among the students? Are students at ease talking about their insecurities and failures as well as their successes? Is there recognition of diversity among the student body and the body of patients—eth- nic and national diversity, marital status, sexual orientation? Does the school pay attention to their individual needs? What are the forces that may subtly and incrementally alter their innate sensitivity and values?
• The location. Where is the medical school or residency program located? Big city or small town? Do the qualities of the community—ethnic makeup, cul- tural offerings—meet the needs of the physician-in-training? For those who are single and looking for a life’s partner, what are the possibilities? For those with a family, what does the community offer?
“Institutions cultivate what they honor,”2 a colleague has said. When medical schools and residency programs teach the human side of medicine as an essential component of training, throughout the curriculum, mod- eled and practiced by its physician-teachers, then those programs indeed support, refine, and reinforce the humanity the student brings. But when the human side is taught haphazardly and sporadically, with leftover time, then students can begin to question its worth. Time can be a barrier. Pro- grams must allocate time to teach, model, and practice the human side. More and more medical schools and residency programs are devoting ade- quate time to address and teach these issues. I encourage my students to seek out those places.
Times change, along with information, technology, and interests. Changes affect what we do as physicians and where. Changing where we practice is not unusual as a career evolves. Some physicians, even without moving, have altered their practice situation to spend more time with their families. Physicians teach, lecture, advise, mentor, and write during their active professional years and thereafter, and they volunteer in health pro- jects for the underprivileged at home and in third world countries. Many physicians are fine musicians.
Being a physician requires a commitment to lifelong learning. Even the timeless part of medicine, the human side, requires growth as we learn better strategies for speaking with patients and relating to them. Beyond the formal settings are the daily teachable moments with patients and col- leagues and sources outside of medicine.
Being a physician provides many opportunities for doing something new. In the process of arranging a program of lectures and support for the staff of a nursing home many years ago, I asked a busy physician-teacher, the dean of St. Paul psychiatrists, to suggest some names of those who would lead such a program. “I’ll do it,” he said. “I always like to do some- thing new each year.” Hardly any profession provides as many opportuni- ties to learn and to grow.
In dealing with stress, competence helps. Having an adequate fund of knowledge and knowing how to apply it appropriately minimize the num- ber of stressful situations. When they do arise, it helps to ask, “What is this all about?” and “What can I learn?” Both questions liberate. It helps to have a confidant—a close friend, co-professional, peer, or life partner—with whom to share problems and feelings. Sometimes it is actually better to talk it over with a nonphysician who sees things differently.
Then there is the camaraderie with others in the healing profes-sions—physicians, nurses, social workers, clergy, and other hospital and of- fice staff—and the joy of collaborating with them, of teaching and learning from these validating peers and kindred spirits. “[When a physician] spends hour upon hour with people [i.e., patients] in whose company he has to ef- face his own needs,… he begins to feel a powerful need to be in the com- pany of his colleagues, to exchange experiences, to learn, to feel secure, to obtain encouragement and support, even to hear objective criticism: to feel a sense of belonging to a framework, a tradition backing his work.”3 A doc- tor connects with very interesting people.
How we integrate our personal and professional lives varies. Sometimes there is simply no choice—the emergency that the on-call physician, the only doctor in town, or the only plastic surgeon around must handle. Then professional duty takes precedence over personal matters. But where there is a choice, where a physician is one of many, then we have the opportunity to define and act upon our priorities. There is life outside of medicine.
Physicians make different choices. Some consistently work well into the evening; others stop taking new patients when they find their practice is too busy. Some work less than fulltime. More and more, physicians are trimming their practice hours in order to spend more time with their fami- lies. I know of a surgeon who spends a day a week at a monastery. When he declined to run for reelection to the U.S. Senate after his diagnosis of lym- phoma, the late Paul Tsongas declared: “No one on his death bed ever said, ‘I wish I had spent more time with my business.’” What kind of physician we choose to become—not simply what specialty but also how we conduct our professional life and shape our career—has a great deal to do with our values. Part of many physicians’ routine is periodically asking the strategic questions: “Where do I want to be in the next year? In five years? Have I stuck to my values?” A medical career provides the opportunity to fashion a life’s work that meets our needs. A friend taught me, “Who you are depends on where you are.”
A medical career is privileged in many ways. Among them are stimula- tion from the beginning to the end, the variety of ways to serve, and the op- portunity to change and grow in ways that maintain our values and preserve the joy of the career.