On Becoming a Physician – Cultural Pluralism

No critic can confidently state that the life of a physician is an easy one. While some might quietly grumble at the seeming excesses in salary and presumptions of self-importance characterizing many physicians, it is well known that the training of physicians is a long, arduous, and expensive process to he or she who suffers the journey and transformation. The considerable starting capital required, despite a needlessly complicated system of need-blind loans and scant scholarship funds, serves its purpose to limit the size of the physician population to a manageable number. This financial cost, along with the cost of time and great effort, furthermore introduce an undesirable factor by all accounts: a psychological challenge issued to the student, spurring the emergence of a tendency toward victimhood or the humble devotion to a life of service, a culture of exclusive self-interest incompatible with a professional mission of benevolence.

A transformation is inevitable. During four years of medical school and many more years of graduate level training as interns, residents, and fellows, the next generation of physicians is circuitously exposed to varying degrees of emotional and psychological trauma – shocks to the old system in order to encourage new, unfettered growth like controlled fires staving off the threat of environmental catastrophe. Our nights with the dead, our frustrations with the living, and our growing awareness of the broken wills of our predecessors seem to paint a ghastly backdrop for our future careers. The shared moments of excitement and admiration of parents, teachers, and friends are now outnumbered by sobering expressions of concern. It is not difficult to see how students of medicine, burdened and discouraged, might fall prey to a self-image as a victim. It makes us impatient, intolerant, and demanding. Whether leading to sighing resignation, bristling indignity, or utmost attention to profit, the response is essentially the same: all express defeat to circumstance and the shaping hands of external forces.

It is sometimes with regret that we, as civilians and recipients of medical care, express admiration for truly great physicians: men and women of exceptional quality of character (quality of skill often assumed), seemingly so few in number. It is often with little hesitation that we, as physicians or students, see ourselves as better than the majority of other physicians, nurses, and therapists: we consider ourselves the exceptions. Instead of presenting a unified front, we obliquely criticize our nameless and distant colleagues when challenged with the slightest apprehension from patients. Upon my entry into the long training process, I looked with hope upon physicians as a professional group united by a pact of core principles. Though as a relatively new student of medicine I am comforted by shared similarities with my classmates, the gradually increasing differences in character and motivations impress upon me a great divide in the culture of our profession. In some cases, faults of character predate the training process (a penchant for irritability, or perhaps a display of dishonesty in a setting so simple as sharing limited supplies) and are easy to hide from the processes that screen for deviation. However, these pale in comparison to the faults espoused by a defeatist attitude, if only in the number affected and displaying these qualities. In viewing our conditions as unfair and our only brave approach as brazenly entrepreneurial, we allow ourselves to find a station in a baser vision of humanity and human nature at the expense of our dignity, and more importantly, the qualities that define us as physicians.

What makes physicians any different from any other individual? Physicians are not better people: we have self-interest, we make mistakes, and we begin no less flawed than any other. However, we cherish certain qualities in great physicians: they put on display the better parts of humanity, including charity and unconditional love of one’s fellow man. They are intelligent, dignified, and consistent in their devotion and demeanor. They are leaders in the hospital and clinic as well as in the community. They encourage us and inspire us to try harder to care for ourselves, and in doing so, celebrate life in ways that only those who dedicate their lives to medicine can. Those aforementioned burdens, financial and otherwise, are only undesirable in that the favored result is clear: the medical profession, as a whole, has not risen to the challenge of defending itself in a manner that keeps its dignity and core principles intact. The mass movement toward “lifestyle specialities,” the perspective of some senior physicians of current students and young physicians as selfish and fussy, and an emerging demand for better financial education for physicians (in the spirit of “defensive driving”) attest to this failure. Why doesn’t our professional culture succeed in inspiring, reinforcing, and rewarding these qualities of great physicians in each of us?

In truth, the caliber of character of many physicians drives them beyond the goal of excellence to devotion to a profession of service. However, the efforts are centered around the individual, unresponsive to unfocused efforts to mold each new generation of physicians. The call for “professionalism” is a weak cousin to the call to duty of the armed services. Unlike men and women of faith, we do not speak enough of our responsibilities as a “service” to others. Though we may save and protect lives not unlike men and women serving in the police and fire forces, we do not uniformly feel a sense of civic duty. We are not a “band of brothers,” and we are not driven to honorable conduct for the sake of honor. The language surrounding the profession does not speak to these sentiments or any meaningful notion of unity. Medicine in the 20th century was, in many ways, an aristocracy: seemingly invulnerable to loss of status and esteem upon the achievement of degree, regardless of performance and minor deviations in conduct. Now, ever scrutinized under the public’s watchful eye, burdened by profiteering bureaucracy, and disarmed by those who would encroach upon the formerly sacrosanct patient-doctor relationship, physicians have no unifying words or rallying cry from which to draw strength. Our code, the Hippocratic Oath, is more a contract than a mission statement: at this time, it serves to bind us rather than commit us to service. In a field that has facilitated and celebrated the freedom and autonomy of the individual physician, we are now vulnerable in our disunity. We are splintered, fragmented, and untrusting of our fellow physicians.

While some may wish to buttress their positions and wait out what they may hope will wash over and dissipate in time, there is no honor or respect earned in fear. The American medical community has changed in character and manner immensely from century to century, and there is no rule stating that the 21st century must see the continuation of flawed systems and bad habits. The internal culture of the medical profession must change in order to address the needs of a new century. In times to come, if ever we wish to lead our communities, we must learn to temper our internal squabbles and tendencies toward forming factions. On my part, my first effort in this direction is to systematically attend interest group meetings for as many specialties in medicine as I can find – to understand the motivations and perspectives of my colleagues. As it becomes ever more difficult for individual physicians to practice alone, we must learn to view our colleagues as equals, regardless of field. Despite differences in experience and “rank,” we are part of a larger community, one unified by a commitment and something else. To what will we commit? Medicine? The well-being of our patients? Excellence? What will that additional something be? Honor? Duty? Benevolence? Instead of trapping ourselves in an unsolveable puzzle simultaneously requiring humility, a drive for excellence, and perhaps a guilt-ridden or brash sense of pride in the face of adversity, it may help to unite around a central commitment: the service of others. In devoting oneself to the service of others, it is not possible to be too proud of one’s work or ability. In wearing one’s commitment on one’s sleeve, one is not as easily scorned for working merely in self-interest and for profit. In taking the responsibility to lead our communities, we may shed a culture of ineffectuality, self-interest, and victimhood in exchange for a culture fostering strength, capability, and benevolence. The circumstances may not change to suit us. But we can.

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