Syracuse, NY 13210
Volume 6, 2006
Letter to a Young Doctor
Medical Alumni Writing Award Winner
My dear friend and colleague,
I was well into my internship before the real challenge of doctoring showed itself to me, like a quiet, dark figure hunched at the rear of the bus. It was one that no one had warned me of. It was one that no had prepared me for. I knew about the hard work. I knew about the responsibility. I knew about the long years of preparation. All these were nothing to me but cheerful, chattering companions on an otherwise solitary journey into professional life. The real adversary, however, was never mentioned. Not then, and, I warrant, it is not mentioned to doctors in training now. Even in mid-life it eludes me. It taps me on the shoulder, but in turning I see only the reproach of a receding shadow.
The real challenge of medicine is loneliness. In so many ways, you will never again be allowed to be yourself. And the role you play separates you from both yourself and from every one else in your life. You are already and will be forever set apart. Indeed, you cannot serve without being set apart.
The isolation imposed by medicine has several origins. First, your knowledge separates you. This process begins early, when you distinguish yourself in high school and then, to a greater degree, in college. As a premedical student, you are something of a pariah. You are a bit uppity, very neurotic. Perhaps you over-estimate your ability. Your solace is a sense of superiority and the honest feeling that you will be able to serve the greater good.
The divide widens during medical school, beginning with the baptismal ritual of dissecting a dead human being. Few of us ever after use the knowledge gained from that experience, but gross anatomy forms a bridge across which you pass into a wholly new, hallowed, untouchable and often resented state of being.
As you learn, you leave your family and the rest of society behind. They begin to look up to you; as you climb, they will never treat you the same. The older brother who used to tease you won’t feel quite so comfortable doing that any longer. When your aunt talks to you about her arthritis or her palpitations, she is not thinking of the little girl with the upturned nose who played in the twilight for hours and came inside laughing and lit up, asking for cookies. That little girl is gone. When your father looks at you now, it is with a new kind of formality and deference. The greater your knowledge, the more remote you become. The distinctions offered by medicine leave you alone.
You may say that you still have your colleagues, that while you are distinguished from society at large, you can still enjoy the companionship of your peers in medicine. For me, this never really seemed to work. In school, there is the competition. After school, you are moved about the hospital chess board according to other people’s needs: patients, departments, practice groups and according to your ability to perform functions
for others. Of course anyone who works serves the organization. But there is something uniquely isolating about medicine. No doubt you have already felt its keen knife-edge. My question is, “Did you cry out?”
The loneliness has its real origin in the general agreement in society and in organized medicine itself that physicians are not allowed to feel anything other than compassion. Exhaustion, rage, revulsion, fear. Nearly every day of your work you will feel these things. Yet your profession requires not just that you deny it, but that you not feel it in the first place. What would people say if they knew that their doctor was frightened? I was frightened most days of my residency to varying degrees. You will be frightened too, when you are the first to respond to an emergency or when a long call night brings disaster to your feet. You will be frightened, and you will be excruciatingly, utterly alone. And you won’t be allowed to tell anyone.
When you begin practice you will spend hours listening to patients drone their stories in irrelevant and disorganized fashion. The information you need from them could be conveyed in five or six phrases. But instead of answering your questions, they will answer another question, one posed by their own anxieties. Sometimes, you will have to ask the question three or four times, but you cannot show impatience or annoyance. That would indeed be unprofessional. And the power you wield is enormous, so that a frown or clipped phrase has the capacity to devastate.
All of these “shoulds” relentlessly divide you from your own nature. You will be tempted to defend yourself with cynicism. This is the natural callus that develops to protect you from repeated injury. It develops frequently during residency and is probably necessary for your survival. Do what you must to protect yourself. Beware, however, that the callus will separate you further from your feelings and from other people, patients, friends, and family.
Physicians have been likened to priests. There is merit to this analogy. It illuminates both the privilege and the loneliness of medical practice. Physicians and persons of the cloth are held to a higher standard of behavior, and they should be. Both professions require some sacrifice of the family. The priest and the physician both pay a high price to belong to these sacred orders.
What advice can I give you? Only advice that I have not followed. It is: Tell someone. Don’t jump off the roof. Tell someone. Admit that you are afraid or uncertain or whatever you feel. Don’t deride yourself silently for your fear or uncertainty or nauseating impatience. These feelings are normal and natural, and most students and young physicians feel them too. Find someone you can trust, preferably a peer or a mentor, and tell them. The chances are very good that they will know what you are talking about and be relieved to hear you say it out loud. I say be wary of anyone who says they have never felt fear, rage, contempt, impatience in the conduct of their profession. That person is deeply divided from their humanity. Most would not want such a physician.
The irony in all of this is that patients want doctors who feel things. They want emotional connections, however brief, with their healer. Such encounters have tremendous healing power in both directions: healer to patient and patient to healer. In truth, some of your patients will be your healers. For you will find yourself sealed into that lonely place where your first duty is to know what is wrong with the patient, know what to do about it and act in the best interest of the patient, regardless of how much agony you may be in at the moment. Often, only the patient can reach you through that barrier of professionalism. The patient can see your sacrifice and suffering and their gratitude will rise and crest, then break over you. Briefly, the barriers will be washed away. When you feel that grace, remember that you did not reach that place by learning and knowing alone, but by sacrifice that hurt you and likely hurt others near you. You can arrive there only if you care more for your patient than for your own ease. It is a steep and rocky path. But there is no other path to the real honor and privilege of medicine.