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Reflections on year three

2010 August 24

Last week, I finished my first year of clinical training in medicine — the comprehensive year — which will be followed by another year of clinical electives before I get called “doctor”. It was, in a word, tiring. The peak of difficulty was the eight weeks of general inpatient medicine at the end of 2009, but this was followed by seven months of ever-impending exams, constantly studying and constantly feeling ignorant, very rare weekends off, extended periods of regular all-nighters, and the surrender of all extracurricular activities and most of my social life. I saw doctors provide suboptimal care, I saw them prioritizing physical outcomes over psychosocial outcomes at nearly every turn, I saw them intentionally exclude competent patients from decisions about their own health care, I saw them quickly leave the room when patients became tearful, I heard them wishing for more than their million-dollar taxpayer-paid salaries, and I even absorbed their direct verbal abuse and their wayward used surgical needles. I had to play along with all this, reinforcing it, and saw myself avoiding patients’ concerns and letting substandard care go uncriticized, in order to preserve the unity of the health care team and my standing in the eyes of the doctor who was grading me. And I had to pretend to love every minute of it.

I kicked off the short vacation between years with a hike with one of my dearest and most cheerful friends. As we scrambled down the mountain, she asked me for advice that might serve her as she, too, pursues a career in medicine. I was grimly detailing all the challenges she would face when my negativity struck me quite forcefully. Inspired by the example of my optimistic friend, I remembered that negativity really isn’t something I would like to cultivate.

I thought: was year 3 all bad? Certainly not: I had a perfectly joyful time with friendly, encouraging doctors in pediatrics, anesthesia, psychiatry, emergency, and general surgery (despite the latter having been the busiest rotation of all); all the other rotations had some really good moments and were very educational despite the episodes of discomfort; in obs/gyn I wept along with new parents, and I worked with a doctor who’s survived two murder attempts as thanks for his invaluable work; and for my elective I did a laid-back but intensely inspiring two-week elective elective in public health where I immediately got along well with everyone I met. The negative experiences above were especially salient, but I believe nearly all of them represented exceptions rather than rules. Most doctors I worked with really were great.

I thought further: have I felt down about med school, and life in general, before? Of course I have! Through significant chunks of first and second year, I felt like I was studying all the time; I often felt lonely and intimidated by my classmates; and my volunteer responsibilities provided an extra source of anxiety. But also, I was routinely thrilled by what I was learning; I made a whole bunch of the best friends I’ve ever had; I found the volunteer work really rewarding and inspiring; and overall I feel like a very different (better!) person compared to when I started med school three years ago.

And that strategy of pretending to love every minute of it? There were times when it actually worked! Most notably, after the blow of internal medicine, I realized my lack of enthusiasm was a vicious cycle, so I spent the first few days of general surgery taking extra care to be a keener — and soon found myself actually enjoying it. “Think happy thoughts” sounds facile, but it really does work.

And most of all, my underlying optimism — as soon as I stopped to think about it — remained intact. A busy and often-stressful period often pushed these thoughts out of the forefront of my mind, but I know I still give everyone the benefit of the doubt and I still find the good in everyone, I am still optimistic about the state of the world at large, I still have faith in many of its imperfect institutions, I am still honored by every individual who trusts me with very private matters, I am still grateful for the opportunity to help them improve their well-being in some way, and I am still excited about and confident in my ability to play a role in helping a lot more of them in the future.

I routinely recall with fondness what I heard from a resident back in first year, at an event I attended on fostering advocacy and activism among medical professionals: that there had been a survey showing disillusionment with medicine and feelings of inability to engage in activism peaking by the end of medical school, and tending to resolve thereafter.

Now I face the somewhat stressful decision of picking a path, and the frustration of seemingly limited my positive impact is going to be for at least the next few years. (That’s my biggest problem? I wish I had my problems!) But again, once I stop to remind myself that there are better ways to think, I know there’s no way to make a perfect decision and I surely won’t go too wrong anyway. And while one person certainly can make a difference (and this one certainly intends to), feeling able to take personal credit for improved social welfare is really not a desirable or even coherent goal anyway: really big changes are never the work of just one person, and they never happen overnight. And so many people are already doing such amazing work: I might end up leading a charge that I think is important because nobody else is doing it, but I don’t necessarily need to reinvent the wheel, and I know I won’t get anywhere on my own. I want to figure out how my strengths can most effectively boost a collaborative effort. I don’t know what that’ll be yet, but I know I’m gonna love it!

10 Comments leave one →
  1. 2010 August 25 08:17

    “Possibly related posts: (automatically generated)

    * Wuh?
    * Panting means Pain
    * Chickens!”

    But seriously, it’s good to hear you’re beating times of adversity with optimism!

    • 2010 August 25 08:25

      Hmm yes! I think I will give the “related posts” feature a chance to resign gracefully.

  2. 2010 August 25 09:03

    A bold and fearless assessment. Glad you made it through.

    Remember: that which does not kill us can only make us bitter and horribly disfigured….. or stronger.

    I like your mention of willing happiness to achieve it. This has worked for me as well.

    • 2010 August 25 09:17

      Mostly fearless! If I’m going to be a semi-public figure that tackles political issues some day, I probably have to start thinking like a politician and be careful not to say anything that could be too easily taken out of context and misinterpreted, especially here on the INTERNET where nothing is ever forgotten.

      Also residency programs might look me up when I apply for a position, and here I am talking about how awful medicine is and how maybe I have some depression/anxiety sometimes. Haha! I have faith in institutions though, and I think they won’t be so easily turned off. Attention residency programs: I am being dramatic, I really do think medicine is excellent, but we tend to hold those close to us to the highest standards, and all the above problems seem well publicized within the profession; and I think the occasional bout of negativity/anxiety is completely normal.

  3. 2010 August 25 17:25

    It’s certainly worth bringing up negative feelings/experiences if they are at least one of: systemic, significant, avoidable, or addressable. But does this mean your overall spiel re: med should be negative, especially to someone just starting out? Probably not, if you truly believe that your less-than-positive encounters with staff were exceptions rather than rules. I think we’re on the same page.

    Still, I personally would rather hear novel insights on the challenges of a certain career path, than reflections on positive experiences (unless they are exceptional). For one, it’s more useful to be able to anticipate hurdles that lie ahead… then you can be well-prepared or pleasantly surprised! Also, problems are that much more interesting (and discussable!).

    I wholeheartedly agree (though I need to be reminded from time to time) that negativity, for its own sake, is not worth cultivating. But I think it’s absolutely vital to nurture critical thinking in society, even if it often means bringing uncomfortable views to the table.

    • 2010 August 26 08:02

      All hail critical thought!

      The problem-centric mindset is a great way to solve problems, but with a potentially endless succession of problems it also lets us forget about what’s good. We see patients as walking talking bundles of physical ailments; we portray populations primarily in light of their deficiencies relative to our norms. So yes we should honestly address problems, but in order to foster hope and pride and agency — important bulwarks against future problems, for everyone from health care workers to First Nations youth — we also need to discover and celebrate strengths.

  4. 2010 August 26 08:47

    As long as celebrating aspects of the human experience that are good doesn’t cloud the perception of problems that remain. The cynic in me wants to argue that excessive optimism breeds complacency. Case in point- the ongoing self-congratulatory rhetoric of using reusable bags to ‘save the earth’ detracts from some of the major causes of climate change (diet, overconsumption) and the urgent need for meaningful political action on this front.

    A point you touched on, I think, is the realist approach of recognizing the strengths of individuals and communities, and leveraging those to push for needed change. It’s not always easy to find that golden middle ground in which you remain just angry enough to keep pushing, yet positive enough to remain magnetic to those around you.

    I’m always surprised to hear of the purportedly low rates of job satisfaction among physicians, because my personal experience suggests that the medical profession is overwhelmingly populated with motivated, enthusiastic, happy people. Perhaps it is sample bias- as an outsider, I only met the ones who had enough of a work-life balance to be able to attend external social events and the like?

    • 2010 August 26 09:23

      There are two sids of a coin here: you seem to want to limit celebration to that which doesn’t cloud perception of problems, but why is that better than the converse, of limiting attention to problems to that which doesn’t interfere with joy? It seems like a choice between which sand you will stick your head into!

      Tackling a problem in one insufficient way doesn’t necessarily detract from other ways; that view seems to assume that our capacity for social transformation is limited but highly flexible, so that if people weren’t being placated by this triviality, they would be agitating for a revolution. Maybe the bag issue is the thin edge of a wedge, and the first baby step in a gradual overhaul of our environmental impact (so capacity is not limited). On the other hand, maybe it’s a manifestation of the dominance of consumer culture and apathy, to the point where acts of individual consumption are the only “political” actions most people feel empowered to take anyway (so capacity is not flexible).

      Personally, I don’t like being angry! Anger’s not what motivates me at all, so that’s not the balance I’m striking. Maybe it’s an irrational ideological/emotional stance, but I feel like I have too much morally-relativistic imagination to really get angry at anyone. I think hope, optimism, and recognition of/inspiration from the work that went into the triumphs of the past, are at least as good for staying motivated to do something good for the world as anger. The main middle ground I straddle is between pushing myself too hard and burning out, and abdicating responsibility to the point where I do too little.

  5. 2010 August 26 10:14

    Why not, as you put it, “‘[Limit our attention] to problems to that which doesn’t interfere with joy?”

    Because it could be used to justify ignoring so many injustices. For example, let’s celebrate only what is good about Science! Let us expound on its accomplishments and victories; let us praise the Famous Scientists who helped advance human health to where it is today; let us ignore the struggles of women and minority group and developing world researchers, because they might threaten our otherwise unabashed collective joy.

    It’s an extreme example, and not one I think you would be likely to engage with, so go ahead and suggest it’s a slippery slope argument, but my point remains: I believe it is important to keep the forward momentum going, and to stay focused on tackling challenges that remain, in light of and motivated by baby-step successes, than to dwell on what’s already been done.

    Of course, feeling frustrated with the current state of affairs, and feeling hopeful for the future, are not mutually exclusive. Indignation motivates you (me) to push for a world in which your hope is realized. I’m really pleased that there is space for activists from all ends of the personality spectrum within the social justice movement. Hopefully it’s apparent that I respect and value your outlook in a world where diversity of opinions and approaches is vital.

    • 2010 September 2 10:34

      Right! It was sort of a rhetorical question. Of course it would be bad to insist on unthreatened happy thoughts. But I can invert your extreme argument to the other extreme, and argue that if we only let ourselves feel happy when all problems are solved (which they never will be), then nobody will be able to enjoy their lives, and that would sort of defeat the purpose. I think we can, and indeed must, hold both views simultaneously — recognizing strengths and successes is not mere “dwelling” any more than emphasizing problems is mere wallowing in misery. We need to focus on problems if we’re going to solve them, but if this isn’t balanced by an equal amount of positivity, we risk losing hope or creating even more problems (e.g. stigma).

      I’ll tentatively suggest that, as usual, we probably agree on fundamentals, and this is all a matter of semantic spin.

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