Treatment Kind and Fair
D e c i d i n g t o B e a D o c t o r —
C h o o s i n g a n d B e i n g C h o s e n , a n d M a k i n g Yo u r M o t h e r P r o u d
A twenty-two-year-old male presents with anxiety and disturbed sleep. He has previously been in good health, and has recently applied to twenty medical schools. He describes an inability to stay away from his e-mail, where he is obsessively checking for responses, indications that his application files are complete, and interview invitations. He is drinking six to seven cups of coffee a day. When he does fall asleep, he dreams about kindly figures in white coats with stethoscopes bending over him and listening to his heart.
So you’re really going to do it! You have to give me credit—I may be your mother, but you have to admit, I haven’t pushed you to be a doctor. It was a real matter of principle with me—first that you should choose work that really drew you, and second, that however much I love medicine for myself, there would be something wrong with pressuring you to follow the same path. But you’ve been saying ever since high school that you thought you wanted to go to medical school, and now here we are, and you’re actually applying, and I have a confession to make: I’m totally delighted. And now I can admit several things that I haven’t quite let myself say: I think it’s a wonderful choice, I think medicine will let you exercise and extend all your skills and talents, I think you’ll mostly enjoy the training process (well, I think you’ll hate some of it, but I think you’ll kind of enjoy hating it, and I’ll explain what I mean by that a little later on), and I think you’ll find yourself with a fascinating set of intellectual challenges and choices, and a busy and rewarding professional life. I think medicine will make good use of you, and you will make good use of medicine.
And I guess I’m a little flattered. You may not mean it this way at all—you may look on me as a member of a completely different species—but I can’t help feeling that your decision to go to medical school must mean that you look at your own childhood and feel I did an okay job. You, after all, are my medical school baby. I got pregnant during my first year of medical school, and you were born in January of my second year. You were one and a half when we went to London so I could study for a month at the London School of Tropical Medicine and
Hygiene—wonderful leprosy clinics, by the way, I highly recommend them! You turned two in New Delhi, where I was spending a month as a visiting medical student at the All India Institute of Medicine. And you were two and a half when I started my pediatric residency at
Boston Children’s Hospital, and five and a half when I finished it. In the early 1990s I went on to do a fellowship in pediatric infectious diseases, and I spent a significant part of my professional life then dealing with children infected with HIV, because that was when the
demographics of the AIDS epidemic began to shift in the United States, with more women infected and bearing infected babies.
During all those residency and fellowship years, you were my home model of a healthy child. Every time someone asked a question about development—at what age should a child sit up alone, start to walk, speak in full sentences—I quickly thought about you. You were also
my greatest delight, and since I was working those insane residency hours, I spent a lot of time missing you.
I know you remember there were nights during those years when your father used to bring you to visit in the hospital—we would eat together in the cafeteria. And you made your theatrical debut in the holiday show put on by my group of Children’s Hospital interns and
residents. There was a skit about the emergency room, and an intern’s dread of seeing yet another incredibly complex, incredibly sick pediatric patient. His lines went something like this: “It’s probably a child with multiple congenital anomalies on seventeen medications I’ve never heard of, with a compromised airway and a weakened immune system coming in with a fever of unknown origin—and I’ve already had six of those tonight!” And at that point, the four-year-old you popped out from under a chair, pointing to your ear and complaining that it hurt. And the intern realized that in fact her next patient was a kid with an ear infection—at which point a heavenly choir sang a version of the “Hallelujah Chorus,” with lyrics like “Hallelujah! Hallelujah! This child has got otitis!” Believe me, until you’ve heard a chorus of residents squeezing in all the syllables of various antibiotics, all more or less to the tune of Handel, you haven’t lived (Hallelujah! Hallelujah! We will give him amoxicillin! Cephalosporins!). Don’t worry, you will get to take part in many such shows; they are an absolute staple of medical education. Your youthful theatrical promise is about to be realized. But you will never again be as cute as you were when you popped out from under that chair.
Your early childhood was shaped by the processes and imperatives of medical training, and your whole life after that was affected by my schedule and my on-call rotations and my preoccupations and anxieties. In my darker moments, I sometimes imagined a child telling
me that it had been a rotten way to grow up. So there is a certain thrill, and even a feeling of redemption, in having that child declare his intention of building a similar life for himself.
Okay, now you have to build that life. You understand that this is a long training, you’re going to apply to medical school, arduous all by itself. Then you’re going to do your four years of medical school, and after that your residency—mine was three years, in pediatrics; if you stay with the idea of doing surgery, yours could be anywhere from five to seven years. And then a fellowship if you want to do one—another three years or so of training and research in a subspecialty. This is how you are going to spend your twenties and probably your early thirties. Recently, I met a young woman who was finishing medical school and was applying for a residency at the hospital where I work. She said something that I liked very much. She said her decision to go into medicine had come about in part because she so liked being a student, and she wanted to find a career where she would be a student for her whole life. Medicine will give you that, and I hope you will enjoy it. You will be a student and a teacher.
So what I’m going to do now is tell you how I have spent my own life as a student. I’m going to tell you what it’s like learning to take care of patients—to listen to their stories and to touch their bodies. I’m going to tell you about the challenge of keeping up with science as new discoveries are made, and about the complexities of making a living as a doctor as medicine changes. I’m going to tell you why it’s fun for me to get up in the morning and go to work—and sometimes why it’s hard for me to fall asleep at night, because I’m worrying, or beating myself up. I’m going to tell you about the choices I’ve made within medicine, but also about some of the ones I wish I’d had the chance to make—and about all the others that are open to you.
Once upon a time, there was a belief that people went into medicine in order to make a good living—well, okay, to get rich. They would be rich doctors whose wives wore mink coats, who played golf on fancy country clubs. I remember a humorous novel called The Serial about upscale life in Marin County, near San Francisco, in the 1970s. In one scene the protagonist, a guy who works in a bank, finds himself taking a woman to a fancy French restaurant, and he realizes, to his distress, that the parking lot is full of luxury cars with MD license plates, which immediately tells him he’s way out of his price range. Sure enough, the restaurant is full of doctors, and our hero is thoroughly humiliated; he has to pretend to have a sudden attack of back pain and beat a hasty retreat.
I don’t think that scene would play well today. Doctors earn perfectly respectable incomes, but if you meet anyone who’s going into this field because it’s where the money is—well, how can I say this?—I would not trust that person to make a diagnosis involving native intelligence, efficient fact-finding, or basic good sense. I promise you that many of your college classmates are going to be getting rich on Wall Street or in corporate law or business, while you are working eighty hours a week as a resident, earning something that comes out perilously near the minimum wage when you calculate it on an hourly basis.
That doesn’t mean I’m whining, and neither should you. Doctors are definitely not poor. What medicine does offer, in the making-a-living category, is a chance to earn a respectable income doing the thing that you will have trained to do. If you train as a doctor, you will work as a doctor, and that is no small thing. But the much bigger, grander thing is that medicine will offer you a chance to earn that respectable income by doing something genuinely interesting and genuinely rewarding every single day of your working life, by staying in touch with science and technology, and by getting in touch with the lives of other people.
You are struggling right now with your medical school application essays, and I know that it can be hard to find a new way of saying all these things: I want to help people (please, whatever you do, don’t say that; when I worked as a premed adviser, I spent much of my time crossing it out of students’ essays. Yeah, yeah, we know, you want to help people—now tell us something we don’t know!). I want to combine my interest in science with my desire to help people (what did I tell you about saying you want to help people!). I think medicine will be a very rewarding career (yeah, you and everybody else—and let me guess, it will be rewarding because you’ll get to help people, right?). On the other hand, all of these things are perfectly true: medicine will put you in a position to spend your professional life helping people, and that is profoundly rewarding.
When I was a first-year medical student, we were matched up with clinical tutors. Each group of four medical students would meet with a doctor who was supposed to take us into the hospital and show us a little real medicine. My tutor was a pediatric intensivist. She worked in the pediatric intensive care unit, with the sickest kids in the hospital. Horrendous trauma, overwhelming bacterial infections, life-threatening respiratory distress—to get into the PICU, a child had to be so seriously sick that almost half of those who were admitted didn’t make it out. That’s unusual in pediatrics—a 50 percent mortality rate—and it’s grueling. Even the mortality rate in pediatric oncology is down around 10 percent. Nobody ever gets used to seeing children die. But I still remember the day our tutor told us a harrowing story of a healthy, happy girl who had contracted toxic shock syndrome and had come close to dying. She had needed massive technological supports for her heart, her blood pressure, her
lungs. Listening to the doctor describe it, we got the sense of a personal battle that the intensive care unit staff had fought, hour by hour, body system by body system, to keep this child alive, while they waited for the antibiotics to turn the infection around.
And they had won. The girl had turned the corner, she had come through, our tutor told us as we made our way to the girl’s hospital room. And now—our tutor threw open the door with a flourish and announced, “This is the glory of pediatrics!” And there she was: a kid, sitting up in her hospital bed, laughing and being silly with her parents. And that is the glory of pediatrics: that children, when they recover, go back to being children, that they are as resilient as they are, that when you win a battle like this, you win it for decades and decades of healthy life. My tutor didn’t actually say to us—worshipful, awestruck first-year medical students that we were— tell me why anyone would do any other job than this, but we understood it. And we also understood that her sense of pride and sense of victory were rooted in the reality
of other battles lost and other pediatric bedsides where there had been no laughter and jubilation.
What a good and interesting job you’re choosing! It’s a job that in the larger sense touches every human being— we all go through this world in bodies, and we are all literally and figuratively touched at so many points by illness and by the medical profession. Doctors are engaged with individual humans at the level that makes everyone human.
I don’t know if you can understand—I don’t know if anyone your age can understand—how thrilling it is to see you make this choice. When I interview intern applicants, every time I talk to one who is smart and tough and idealistic (and most of them are smart and tough and idealistic), I feel a sharp sense of joy that this young person is going into pediatrics. And I feel a broader, deeper sense of pride that medicine as a profession continues to exercise its pull.
But there’s something else as well—there’s the mom thing, the woman thing, the family-and-career thing. It’s not my favorite subject, but it needs to be talked about. In 1982, when I started medical school, the entering class was about 30 percent female. And that felt good; I didn’t feel like the only woman in the room. I didn’t feel that I had to get everything right, or that I had to be one of the best students. No, I felt I was part of a strong female presence. I can remember paging through old medical school yearbooks, though, yearbooks from only fifteen or twenty years earlier, and seeing page after page after pageof clean-cut young white male faces, and thinking dizzily about how quickly medicine had changed.
Your medical school class will be fifty-fifty (with both the men and the women significantly more varied by race and ethnicity than they were in my era)—and that means that you will be in a profession, overall, that will be fifty-fifty. Not necessarily every subset—there’s plenty of variation from urology to psychiatry to cardio-thoracic surgery to ob-gyn—but fifty-fifty overall. That is remarkable. Yes, I could lecture you about the need to promote more women to positions of authority, the need for more female department chairs, the need to encourage women to go into the surgical subspecialties in greater numbers. But we should also celebrate the reality that a female medical student is now just a medical student, a female doctor is just a doctor.
In the late 1980s, I wrote a story for the New York Times Magazine about the greater number of women goinginto medicine, which they published under the title “Are Women Better Doctors?” I didn’t think it was the best title. Yes, I had asked the women doctors I interviewed whether they thought there were differences in how men and women practiced medicine, and yes, the women had essentially all said, yes, there are differences, let’s face it, we’re better! But I meant to include this halfhumorously, more as evidence of woman-doctor pride and solidarity than anything else. The story ran with that title, and I got dozens and dozens of angry letters, mostly from doctors, male and female, all objecting to the title rather than to the article. The question itself was offensive, they said. A good doctor is a good doctor; there are bad female doctors and good male doctors and vice versa. How would you like it, several of the letters queried, if you saw an article published with a title like, are men better doctors, are whites better doctors, are Jews better doctors?
And they weren’t wrong—it was an offensive formulation— though I also remember thinking at the time that it would be good if we could all lighten up a little. I was reminded of an incident in medical school when the admissions office began to object that the women’s medical student organization was making special efforts to host visiting female applicants, and the minority students’ association was hosting minority applicants, and so on—and it wasn’t fair, the admissions officers complained, because no one was specially hosting the white men. There was a pause and then someone said, wow, so do you think there’ll be any of them in next year’s class?
I closed that New York Times article with a story about you—I think you were three or four at the time. It was about the time I told you that you were going to see your new pediatrician, and you looked at me nervously and said, “Is she a nice doctor?” I realized that because you knew me and my friends, you took for granted that all doctors were women, and I needed to prepare you to see your male pediatrician. So I told you, gently but (I hope) encouragingly, that boys could be doctors, too. And look at you now!
Speaking of women doctors, do you remember that particular advice I gave you about medical school interviews? If you’re interviewed by a woman faculty member, I said, be especially sure to emphasize not just that you’re the child of a physician—tell them explicitly that your mother is a doctor. They’ll really like that. And you looked at me a bit blankly and said, “Why do you say that?” And I was completely charmed that you didn’t know why, but all I said was, “It’s a long story, dear. Lots of history. Just trust me on this one.”
So yes, let’s talk about getting in. As you know very well, after four years of undergraduate premed work, this is not set up to be easy. The medical profession regulates the number of medical schools, and the number of places available in each medical school, and they keep the lid on tight. That’s why plenty of qualified undergraduates still end up going overseas for their medical training; there aren’t enough spots available in the 125 accredited U.S. medical schools. In fact, U.S. medical schools don’t graduate nearly enough doctors every year to fill the accredited U.S. residency programs, which is why so many need to fill their slots with foreign medical school graduates. That’s why I can tell you so confidently: If you train as a doctor in the United States, you will be able to work as a doctor in the United States.
But that also means that getting into medical school becomes the giant hurdle. If you get in, then medical school will teach you enough to pass the licensing exam, and you will find a residency spot. You aren’t guaranteed the spot you want, or even the specialty you want. Some fields like dermatology and ophthalmology and certain surgical subspecialties have comparatively few spots and way too many applicants, but unless you are a complete and total screwup (and even then, in many cases), you will end up with a residency and a license and a job as a physician. It isn’t like law: If you’re willing to go far enough down the hierarchy of law schools, there’s a school somewhere that will accept you. There is no limit set on the number of lawyers trained. On the other hand, a law degree guarantees you nothing in the way of a job. Lawyers are regulated by supply and demand. Not so doctors. No matter the demand, the domestic supply is limited to those 125 medical schools, and their small classes. Other doctors have to come in from overseas, pass additional (and formidable) licensing exams, and sometimes do major pieces of their training all over again.
So yes, getting one of those spots in one of those small classes at those medical schools is still a big deal. At least half of medical school applicants don’t find a place in the United States—and remember, these are all students who have managed to complete (and presumably pass) the premed courses. They’ve invested a considerable amount of effort and energy and intellectual capital and sweat, since the premed courses themselves were set up to be stumbling blocks, or opportunities for serious weeding out. But medical school itself, once
you’re in, is not a weeding-out kind of experience. There used to be a legend at Harvard Law School about a professor saying to the students on day one of year one, look to your right, look to your left—one of you three will be gone by the end of the year. The medical school equivalent would be, look to your right, look to your left, we will do whatever it takes to make all three of you into doctors. A medical school has a tremendous sense of investment in every student in the (relatively small) entering class; they are all supposed to make it through and pass their boards and earn their MD degrees and find themselves reciting the Hippocratic Oath.
For this reason, it’s an elaborate and lengthy admissions process. And I have to admit to you that when I think about these admissions committees considering you, Orlando, I have a motherly wish to admonish you in all kinds of traditional ways: Wear a suit! Shine your shoes! Stand up when someone comes into the room! Call your interviewers Sir or Ma’am or Doctor, shake hands firmly, look ’em in the eye!
I focus on the interview because it is so important for medical school. Each medical school interviews only a certain number of applicants for every spot, and they won’t bother interviewing people they don’t think have a reasonable chance of being admitted. So getting
an interview is something of a triumph all by itself. Back in the old days, medical school interviews were legendary. Everybody knew a story about a stress interview, an outrageous interview, a completely unfair outof- left-field interview. The student who is asked to open the window, and it’s nailed shut. Or the student who is grilled at length on the small technical details of the economics of health care in America today, and is never asked a single why-do-you-want-to-be-a-doctor question. You’re unlikely to have a stress interview— even in my day they were more legend than reality. But you better be ready for those regular old non-stress interviews. In addition to your well-polished shoes and manners, be sure you read the newspaper carefully every day, looking for health stories, and be sure you have an opinion you’ve thought out on the big medical controversies of the day. For that matter, be sure you have an opinion on what is the biggest problem facing American medicine today; that’s an easy all-purpose question for any interviewer who hasn’t read your file closely.
Above all, think about how you can convey how much you want to do this. They are looking for people who are passionate and personable—and let’s face it, they are trying to weed out the arrogant, the socially dysfunctional, the total jerks. I heard about one applicant this year who found himself in a group interview situation—four applicants, all presumably sitting there thinking, they’re only going to take one of us, they’re only going to take one of us! And sure enough, one of the four decided to play the jerk: he mentioned his own Ivy League pedigree a mere eight or nine times, he looked visibly bored and disgusted when the other students spoke, he insulted their answers. Imagine how easy he made it for the interviewers; we all know what kind of medical student that guy will make. He was saying, loud and clear, take me and I will be one of the class jerks! I could name you his equivalents in my own class so long ago, and I could tell you their medical school nicknames too, except that they’re unprintable. We all know from our experience of doctors that the weeding-out process is imperfect, but there it is: They are picking some hundred young people in whom to invest their energy, their time, their cadavers, and their imprimatur. They don’t want to waste spaces on creeps. If they take you, they intend to make a doctor of you.
Medical training is transformative. It will make you over completely—your emotions, your sense of proportion, your narrative abilities, and your habits of mind. The process starts in college, as you make the choice to be premed and spend your college years under a certain
amount of pressure. But it’s when you get to medical school that the real transformation begins. I will try to pin down some of the elements of that transformation as we go forward, try to help you see why medical training is more than just assimilating a great deal of information. It also involves assimilating responsibility, and making what we can only call life-and-death part of your daily routine. Maybe this sense of suddenly mixing with life and death is part of why we often compare medical training to military training, why you hear the expressions, “basic training,” or “in the trenches.” It means accepting pain and disease as your familiars, and remaking many of your normal and proper responses to life (yes, I want to see what’s under that bandage—yes, I want to be in that room where the people pulled from that terrible car crash have been brought—yes, I want to be there when we tell the patient he has cancer). And it means changing your sense of identification; I promise you that when you come out of this training, you will in some sense divide the world into doctors and non-doctors, and you will identify as a doctor.
One convention of medical education is that many classes and discussion sessions and conferences begin with a medical case: Twenty-eight-year-old male of Mediterranean heritage presents with pallor and lethargy. The patient states that he was well until four days ago, when he began feeling tired and was unable to go about his usual activities. He denies any fever, arthralgias, or myalgias. . . .
The really good test takers among you should have made the correct diagnosis in the first sentence: Why are they bothering to tell us that he’s of Mediterranean heritage? Must have some significance. Which diseases are disproportionately present in that group? Got it—he has G6PD deficiency and something has made him hemolyze! In other words, you think the patient in the vignette has an inherited enzyme deficiency—he doesn’t have enough glucose- 6-phosphate dehydrogenase. And in the presence of certain medications or certain foods (most famously fava beans), people with this enzyme deficiency start to hemolyze, to chew up their own red blood cells, and as they destroy their red blood cells, they can become severely anemic. So then you read on to see if there are any other clues. . . . The patient states that five days ago he was having back pain, and took some unknown medication provided by his brother-in-law . . . Bingo! There we are. He has G6PD deficiency and he took some medication that set him off and now he’s hemolyzing!
Medical education keeps building on these cases. Sometimes they will ask you what would be your first action. Sometimes they take you through the whole course of the illness, step by step. When I have to recertify in pediatrics, every seven years, I take a long multiplechoice test, and there are those same case descriptions. So you might as well get used to them. After a while, it becomes second nature to formulate the people you meet, the patients you see, in that way. You’re beginning to learn to tell a medical story. As you progress through medical school, you will learn a whole new vocabulary, even a jargon, and a new set of nicknames and abbreviations. You’ll even learn some new grammar and sentence structure. At first it will sound strange to hear yourself speaking in this way: “This forty-five-year-old female, gravida 4, para 3, SAB 1, status/post outpatient surgery four days prior to admission for menorrhagia, now presents with chest pain, rule-out MI. . . .” (She’s forty-five, she’s been pregnant four times, had three children and one miscarriage [SAB, spontaneous abortion], four days ago she had surgery for heavy menstrual bleeding, and now she’s here with chest pain and we’re worried she might be having a heart attack [MI, myocardial infarction]). I promise you that by the time you graduate, you also will be past master at constructing these formalized stories, these information-packed clinical vignettes. Of course, as you get to know your patients well, you will become increasingly aware of what these formalized narratives leave out, even as you become efficient at assembling them.
All your training in medicine is supposed to lead to this, to the ability to interpret the clues and put the pieces together and figure out a particular patient. I started this letter by considering you as the patient— anxious, drinking too much coffee, obsessing over your e-mail, having trouble sleeping, dreaming of white coats and stethoscopes. And as we consider your case, we imagine hands popping up around the room as eagerbeaver medical students comment on the symptoms, the diagnosis, and the management. Avid to use medical jargon, one student comments that this illness is iatrogenic, a word that means an illness caused by the medical profession. Iatrogenic infections, for example, are the ones that patients acquire in the hospital, or as a consequence of medical procedures. Yes, chimes in a classmate, also eager to use medical terms, it’s iatrogenic and it can have a high morbidity, but a low mortality. By that she means your condition can cause you all kinds of harm but is unlikely to kill you. But at least, she goes on, it’s usually self-limiting, and in most cases, it resolves spontaneously. The medical students nod, thinking a little of their own trajectories. They, after all, have all experienced some variant of the stresses now afflicting you, and they do remember those days. On the other hand, now that they are in medical school, life has not exactly relaxed. Yes, they know they’re going to be doctors, they know they’ve made it in—though many of them probably have moments every now and then of expecting to be kicked out, to be told it’s all been a mistake, bad idea, go on home and find something else to do with your life. On top of that anxiety, and the pressures of huge amounts of material to learn and tests to take, and the constant smell of formaldehyde permeating their clothing, many of them are probably prey to the classic medical student anxiety in which you keep diagnosing yourself with all the terrible diseases you study, you keep identifying your own risk factors and your symptoms. That’s what the student is thinking of who considers your case and offers up the comment that indeed your condition is generally self-resolving, but it is well known that it can sometimes be a precursor to another iatrogenicself-limited condition, medical student syndrome. But the pressures and the information overload that bring on these conditions also offer you relief: The more you learn, and the more you apply that knowledge to patients, real or theoretical, the less absorbed you are likely to be in your own woes and symptoms. Maturity, for a medical student, involves understanding that your own case—however interesting it may be to you—is not what the story is really about.