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A Conversation I Have Had
K. Patrick Ober, MD
PRELUDE
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"We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms — to choose one's attitude in any given set of circumstances, to choose one's own way."
Victor Frankl (1905-1997)
neurologist, psychiatrist and Holocaust survivor |
All of the following is the result of two random hallway encounters in which I asked a single question regarding the same medical school rotation and received two amazingly different answers from two different medical students creating such disorientation for me that I sought guidance from
Mark Twain
Mother Teresa
Lance Armstrong
Winnie The Pooh
A Lot Of Starfish Who Were In Big Trouble
and
Albert Einstein
only to come up with the same conclusion as that of Victor Frankl in the Prelude.
(It may be to your advantage to stop reading here, go back and read the Prelude again, and then go do something useful rather than continue on.)
Dr. Ober: "How are things going on your current rotation?"
Student #1: "It’s great! Right now we have a lot of very sick patients with some very complex problems on our service, and I am really putting in long hours to keep up with everything. I am working with a terrific team, though, and I finally have some responsibility for real patient care - it’s really great to be out of the classroom and doing the things I came to medical school for. I have really had to push myself hard, but I am learning a lot by being part of the action. I didn't ever think that I would be capable of all this, and – as overwhelming as it is at times - I will be a bit sad when this rotation is over.”
Dr. Ober: "How are things going on your current rotation?"
Student #2: "It's horrible! Right now we have a lot of very sick patients with some very complex problems on our service, and I am really putting in long hours to keep up with everything. There are too many patients to follow and it is overwhelming. My team has unreasonable expectations for students. I don’t have nearly as much time to study as I did last year. I can't keep track of what's going on, the hours are horrendous, the scut work is phenomenal, and no one is teaching me anything. I can't wait until this rotation is all over."
Dr. Ober, later, in a conversation with himself (in his typical articulate, witty, and insightful fashion), "Huh?"
Let’s ponder this. How can it be? How can two students on the same rotation with identical experiences have such inconsistent perceptions of the experience? And, specifically, how can one of them be so miserable? After all, didn't each one of us tell the Admissions Committee that we were willing to sacrifice our all for the opportunity of tending to the ill and improving the lot of the diseased? (“…and I will always do it with good cheer, no matter how menial the task or abusive the schedule…just give me the chance to do some good in the world, Dr. Admissions Committee Person, and you won’t be sorry you took me! I promise!”) So why does Student #1 seem to be so upbeat about it all when given the chance, and Student #2 so downcast and dismal? What is it about medical school that can create the feeling that something is not right in the universe, an elusive and unnamable something that seems to cause all of us to be a bit unhappy some of the time (which isn't necessarily a bad thing), and that causes some of us to be very unhappy all of the time (which is a very bad thing)?
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"My life has been filled with many tragedies, most of which never occurred." – Mark Twain |
The source of our shared malady, I submit, can be traced to one of the defining characteristics of virtually every student of medicine (and I use the term “student of medicine” in its most generic sense, to include older and established physicians as well as the younger tuition-paying subspecies). In addition to our widely (self-)proclaimed qualities of intelligence, motivation, and altruism, we all have a well-developed (if not hypertrophied) ability to defer gratification. It has been our guiding light. It’s our mantra. If we work hard enough today, the pay-off will come tomorrow. (Or the next day, at the latest.) You know the routine. Suck it up, keep moving, put on the blinders (avoid all distractions), don’t ask questions. Stay on the track. Nose to the grindstone. You will be glad you did. Sometime. Later. (Trust me.)
Medical education is an intense process that requires a phenomenal investment of time, effort, money, and emotion. We watch our non-medical friends and associates become gainfully employed, pay taxes instead of tuition, buy homes, have careers, get married, start families, and in general get on with their lives at a time when we are locked into a perpetual student mode of shelling out tuition dollars and studying endless hours. When we get stressed out about all of the studying, we may guiltily decide to take a break from studying (only to find that we then start to stress out even more about the fact that we are not studying!). And, of course, in those rare moments when we don’t happen to be stressed out about studying or stressed out about not studying, we have all of those opportunities to stress out about board scores and to stress out about class ranks and to stress out about career choices and to stress out about “the match” and to stress out about residencies. Not to mention whatever is going on in our personal lives. And, if we run out of anything else to get stressed out about, we eventually learn enough that we can start stressing out about stress itself (“Do you feel as stressed as I do?”… “Yeah.”… “Didn’t someone tell us in a lecture that stress could cause heart attacks?”… “No, I think it’s cholesterol that causes heart attacks…stress is what causes cancer…”)
So we convince ourselves that this is going to pay off, eventually. If we learn anything along the way, we learn how to defer gratification. And we defer a lot of gratification. Medical students (past, present, and future) are the gratification-deferring champions of the world. Don’t get me wrong. This approach to life (non-approach to life? deferment of life?) can result in a great deal of accomplishment. We all set goals. And we learn to develop a goal-seeking strategy for success…whenever we start to approach one goal, we just replace it with a higher aspiration, a loftier goal, one level higher. We rarely allow our eyes to stray from the next goal. As a result, our careers advance step by step. Each step, each goal, is temporary, a carrot we dangle in front of our own noses to keep us plodding along the track. We use that next immediate goal to distract us from thinking too much about the happiness we are postponing (because we are going to collect that happiness…later…with compound interest…later…really!). Those temporary goals, the carrots on the stick that we hang in front of ourselves (they are chosen by us! it’s purely voluntary! with no sinister intent! - it’s not like anyone forced them upon us, right?) become the surrogates for the gratification we are deferring; we can even create the illusion that we actually might be in charge of the process, because we get to pick our own carrot-goals.
Many of us have been at this process for a while. Let’s think back. In college, we may have rationalized organic chemistry courses as being a necessary evil en route to our ultimate goal (the carrot!) of getting into medical school. Do you remember how medical school classes seemed so appealing to our undergraduate selves when we were so mired in the immediacy of organic chemistry…when the dream of medical school was so theoretical and so far away? Isn’t it bizarre how our goals can morph into new obstacles as we start to approach them? When medical school classes were out of our reach, they seemed so desirable. Now that they are ours to own, they begin to stand as barriers on the pathway to our newer replacement goal (a fresh carrot) of “getting on the wards” (“the wards”!…such a mystical and desirable destination…and we do so want anatomy and biochemistry just to be over…and the sooner the better…in spite of our heartfelt declaration to the Admissions Committee just months earlier: “I have always been fascinated with how the human body is put together and what makes it work, Dr. Admissions Committee Person, and you won’t be sorry you took me!”)
But, finally, at long last, we make it! The clinical rotations! We have arrived! And then, on the wards, we make another discovery. Having arrived here, and even before we can get acclimated to this new world, we fast-forward in our minds to our next goal (a fresher carrot). The clinical rotations, once so desirable, have now somehow become obstacles in their own right! – no longer the ultimate goal, they have become one more thing to tolerate, a hurdle to jump over, a challenge to “survive,” another task to get through (they are the latest version of alkanes and alkenes and alkynes for us to attack with the old familiar intellectual “slash and burn” we know so well: memorize, take test, forget…memorize, take test, forget…). Now we start to talk about “getting through” our internal medicine rotation to make it into our orthopedic surgery residency, or we dwell on how we need to “put up” with psychiatry so that we might eventually become an emergency medicine resident; in any event, all of this medical school stuff is just more hassle to be endured until we get to the goal of entering our residency…when we are at risk of finding that our residency has become an obstacle to be tolerated until our fellowship starts…and then our fellowship becomes a bother until we get to the “real world”…and, then…sadly, so sadly…
Are you are seeing the pattern here?
And if this is feeling more real than you would like to admit, how about a nice guided tour of the rest of your life, in the Time Machine of your worst nightmare, directed by the Ghost of Christmas Future? (My apologies to  Charles Dickens for not mentioning him in the list of consultants I provided at the beginning – he just dropped into my narrative with his Ghost of Christmas Future right now, without warning me that he was coming. Maybe he sees something Scrooge-like in the way we lead our daily lives?) Let’s go with the Ghost for a while, and let him take us on a midnight dream tour of our possible future. Rumor has it that there are a lot of doctors who aren’t so happy with their present lives. (You may not need the Ghost of Christmas Future to find one; they often identify themselves with little provocation.) They feel trapped. Unfulfilled. Underpaid. Unappreciated. Overworked. Miserable. When you find an unhappy doctor, go ahead and ask for details. (You are allowed to pry. You are a student.) And listen carefully to what they say about the source of their distress. It’s important for you to hear it. The despondent ones will give different answers, but it’s really the same answer. They are all doing the same exact thing. Chasing carrots, running harder and harder, faster and faster, but never catching up with them. Deferring gratification as hard as they can. (And then, the Ghost whispers in your ear, why don’t you venture a guess about what kind of people they were in medical school?)
You might be able to predict how the game is played out:
“This isn’t exactly what I want to be doing right now, but I know I will eventually, sooner or later, finally (!) be happy as soon as I can be…
…in medical school…
…out of medical school…
…in residency…
…out of residency…
…in practice…
…retired?
(…dead?)
Wow! I don’t think that was the original plan, was it? Wasn’t there supposed to be some fun sometime, before we got to end-game?
Does this mean that we should discard all the carrots, stop chasing the rainbows, and forget our goals? Never! We need our goals to figure out the pathways we need to follow. The essential change in perspective comes with the realization that reaching the goal isn’t all that important…all of life is lived on the journey, not at the destination. In truth, we will never truly reach our goals (if we do, I would argue that we have the wrong goals); if our happiness can only be experienced when we achieve our goals, we aren’t giving ourselves much time to be happy. When asked by Christopher Robin what he liked doing best in the world, Winnie the Pooh made the essential observation.
“Although eating honey was a very good thing to do, there was a moment just before you began to eat it which was better than when you were, but he didn’t know what it was called.”
Most children experience more excitement in the weeks of anticipation that lead up to their birthday than they get in the five seconds it takes them to blow out the candles on the cake or the three minutes involved in unwrapping their gifts. The value and meaning of Mother Teresa’s life came throughout her years of commitment to the impoverished, unfed, diseased, and discarded humans beings she cared for; it did not occur in the blink of an eye in which she was awarded the Nobel Peace Prize. Lance Armstrong’s Tour de France victories were glorious, but we should never lose track of the fact that very little of Lance Armstrong’s life has been spent in actually crossing over finish lines. An immensely larger part of his life has taken place in the months and years that he spent in preparing to cross over finish lines. (I am going to feel profoundly sorry for Lance Armstrong if it turns out that he doesn’t like riding a bicycle.)
It may all come down to our need to understand that all of life happens on the journey. It is possible to feel some sense of satisfaction and accomplishment as we perform seeming menial and meaningless tasks on our road to greater goals. On our trip to becoming the greatest doctor in the world, isn’t there some real satisfaction to be found in mowing a scraggly lawn or washing a sink full of dirty dishes? (It isn’t very likely that any one of us will become the best doctor in the world, anyway, but all of us can enjoy the small things that can make us happy as we strive to be the best person we can be.)
It’s just a mindset thing.
Heck, even Winnie the Pooh (Bear of Little Brain that he was) understood it:
 "When you wake up in the morning, Pooh," said Piglet at last, "what's the first thing you say to yourself?"
"What's for breakfast?" said Pooh. "What do you say, Piglet?"
"I say, I wonder what's going to happen exciting today?" said Piglet.
Pooh nodded thoughtfully. "It's the same thing," he said.
There is a wonderful story that makes the point in another way. It starts with a terrible storm that washed thousands, if not millions, of starfish onto a beach; the dying starfish could be seen for mile after mile up and down the beach. A young boy stood on the beach. Again and again, he bent down, he picked up a single starfish, and he tossed each one back into the ocean. One after another, he tossed starfish and tossed starfish and tossed starfish until his arms ached more than they had ever ached in his life, but even after hours of effort the beach looked exactly the same as when he had started. The beach was still blanketed with starfish.
An old man watched for a while, and finally approached the boy.
Pointing to the innumerable starfish that were visible as far as the eye could see, the man shared his wisdom the boy: “You realize, I hope, that you are wasting your time? It is futile. What you are doing can’t possibly make any difference at all.”
The boy said nothing to the man. He simply bent down once more, picked up the next starfish, and tossed it out into the waves. Then he turned back toward the man.
“I think I just made a difference to that one,” he replied.
And he picked up one more.
So, after talking with the two medical students who were having such amazingly different reactions to a common experience, and after thinking about it for a while, I started to understand the choices we all have to make.
Each one of us can be Student #2, or each one of us can be Student #1.
Each one of us can keep chasing our carrot-goals and hope that our happiness will start tomorrow, or each one of us can savor the journey and enjoy the events of today.
Each one of us can be the old man, or each one of us can be the boy.
And each one of us gets to choose.
Conclusion
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“There are two ways to live your life – one is as though nothing is a miracle, the other is as though everything is a miracle.” – Albert Einstein | |