“The patient is the one with the disease.”
–Samuel Shem, The House of God
Last May, Evan matched into a fellowship that will take him across the country for a year, beginning in August. Because he’s a little bit off in the head, he chose subspecialty training that will likely entail even longer hours than residency at the same pay scale. This fellowship culminates 15 years of higher education, half of Evan’s life so far: college, a doctorate intended to make him more competitive for medical school, medical school, and residency.
I admire but cannot in the least relate to this single-minded pursuit of a concrete end, chosen at such an early age out of thousands, like a star plucked from the sky. I marvel at the clear trajectory of Evan’s path, its predefined steps and milestones (puns intended). You can imagine the envy a writer might feel toward someone with a set of skills and interests that the world endorses and rewards, ushers past the stanchions into the fold of productive society with a nod of recognition.
At least, this is what I used to think. Now I know better. Over the years, in quiet moments and spaces, Evan has confessed that he is stumbling through a darkling plain like anyone else, overcommitted to a destiny adopted before he could know what it meant. “My life is a lesson in the sunk cost fallacy,” he says. Except it isn’t a fallacy, thanks to hundreds of thousands of dollars in debt.
I worry for Evan. A trajectory this long and austere can only end in a fall. I know he will perform admirably in fellowship, as he has through all his training. Evan is brilliant, competent, and like most doctors, violently allergic to even a whiff of failure.
But in almost 500 days, he will be graduated from fellowship, and what then? What happens when you tick the final box on the agenda that has determined your every move since early adulthood? The yawning vastness of choice could swallow you whole. Who tells you what to do when you wake up in the morning? Who lets you know if you are succeeding or failing? The answer, as most adults know, is no one. That is the terror and the beauty of meaning-making: you do it yourself, and you are never finished.
To someone who has spent a decade and a half racking up degrees and credentials, this represents a new mode of living, a new way of relating to the world. Some attendings cope by continuing to work resident hours, not out of necessity but by choice, because they don’t know anything different. I don’t want this fate for Evan, but I understand how doctors end up there. Because training doesn’t help them answer the most important question of all: Who are you? Underneath your job, behind the professional niceties and customs, beyond style and recognition and material comfort: What matters to you, in this one wild and precious life?
Our relationship to work in America is broken, sometimes I fear irreparably. Work has become our national religion; the Protestant-capitalist obsession with production has made supplicants of us all. Millennials work more and make less than any other American generation in the last century. Even those who need work very little to get by take on crushing burdens of labor — hardly surprising in a culture that regards leisure as a form of moral depravity and exhaustion as a badge of honor. How can we expect to cure burnout when we all believe, deep down, that anything less signals laziness?
Medicine is more vulnerable than most fields to the demands of our live-to-work culture because the knowledge and skills required to practice have increased at a breakneck pace, a pace which itself is ever-increasing. There is simply too much to know, more than the human mind can hold. When surgical residents complain of long work hours, supervisors respond that even five years of 80-hour weeks fail to prepare residents for independent practice. How can we expect to ease the hardships of training when the educational burden only continues to grow?
The main “solution” to this dilemma advanced by most undergraduate and graduate training programs has been to cram more and more into the existing framework, which has created — shockingly — a cohort of depressed, disillusioned medical students, residents, and fellows. Exceedingly rare are discussions of the emotional and knowledge costs of the more-is-more philosophy of medical education, which makes patients the enemy, admissions “bullets.” Hardly ever do we acknowledge the effort wasted by physicians trying to stay sane in an overtly hostile training environment. Imagine what might be accomplished if all that effort were redirected toward learning, caring, innovation.
Trainees are expected to know more, but do not produce more value. In surveys, physicians often cite as a main cause of burnout the perceived inability to help their patients in meaningful ways. The thing is, this is largely a correct perception. The United States spends dramatically more per capita on health care than any other wealthy country, yet our population is not healthier. The burgeoning field of social medicine has shown that, more than any set of medical treatments or interventions, social factors — economic inequality, food insecurity, pollution, discrimination — determine health. Our health care system is like a single stitch in a ruptured abdominal aortic aneurysm. The perpetual emphasis of medical training on the biological sciences leaves doctors unprepared to treat what really ails their patients.
The fundamental practice of medicine must change to accommodate these realities, and that means we must train doctors differently, too. This will necessitate embracing different pedagogical modalities: less memorization, more conceptual, interdisciplinary learning. More time in the community, faster transitions from the classroom to practice. It will also likely require that more programs offer condensed or accelerated subspecialty training, to ameliorate the cognitive and financial drains of medical education. Increased specialization will require all providers to work in teams. As technologies for computer-assisted care improve, medical students will need to learn how to incorporate them into practice. And finally, we must unflinchingly set expectations for trainees of what they can expect from a career in medicine.
But it all comes back to the way we relate to our work. The sooner we think of resident work as labor, the better. “Doctor” is a job — a job unique in many ways, but a job nonetheless, like “accountant” or “carpenter.” Young physicians are victims of the “Do what you love” message that our well-meaning but misguided boomer parents elevated to the level of a generational mantra. Love is what you feel for a person, not an occupation. Better advice for college students would be: “Do what allows you to do what you love, and doesn’t destroy you in the meanwhile.”
It is too much to ask of a person, and too much to ask of a job, that each meet the other’s needs completely. We have forgotten the proper place of labor in human life — a means of survival that lends structure to our days, but otherwise ancillary. The kind of work we do in the workplace can provide partial and tentative fulfillment, but the real work of nourishing the soul must be done elsewhere.
I continue to ask myself: What does “wellness” really mean? I have been turning this question over and over in my mind for weeks, and here is the closest I have come to a provisional answer: To be well is to be most oneself. To know what one loves, what brings one’s life meaning, and to pursue it to the fullest possible extent. This pursuit requires the essential material conditions of what we think of as wellness — rest, shelter, food, water, sanity — but it is the pursuit itself that finally leads us into the land of the well.
It is crucial for doctors to pay close attention to cultivating selfhood, because medicine, more than other fields, continually threatens to eclipse the self. The hospital demands a physician’s time, her body, her expertise, her empathy. We must all squirrel away parts of ourselves, sacred spaces, that work cannot touch. More so from medicine, whose tendrils wind their way into every unguarded crevice. This skill, not detachment but self-protection, must come to form an integral part of medical curricula.
In the end, the greatest barrier to a seismic shift in how doctors work may be the need for doctors to change the fundamental way they conceive of their profession. The physician who styles himself a heroic swooper-in, who prioritizes his patients’ well-being above his own — the very ethical foundation of medical training — will inevitably find himself desolate. The psychological orthodoxy that self-love must precede love of others applies no less here than in a romantic relationship. The hollow but brilliant doctor beloved of television writers is like the tortured but ingenious artist: a waste of a human life. We must abandon, once and for all, the myth that suffering is honorable. Self-sacrifice is an empty virtue. “If we don’t care for our patients, they’ll die,” doctors say. But you are dying, too.
And patients — that’s all of us, by the way — must also reimagine the role of doctors in our lives, and in society. We must acknowledge the frailty, the humanity of our carers. We must not mistake them for gods or magicians, omniscient or omnipotent. We must not hold them to standards of invulnerability. And for heaven’s sake, we must let them sleep.
When Evan crumples into bed after an overnight shift, I slink around the house on my toes, like a cat, imagining a bit of life returning to him with each shut-eyed minute. The longer I can make it last, the more himself he will be when he awakes. I am excited to find out who that self is, as it loosens the shackles of residency and steps into the light of its own splendor. Come June, I offer my congratulations to Evan, and to all those who have made it through, along with a hope: that you not forget these difficult years, painful though they be to recall; that you demur from reenacting the torments that were visited upon you, and you admonish those who do; and that you use whatever power you have — you have more than you think — to pave a kinder path for future generations of doctors. Here’s to you.