From the Forward
Medicine is a way of life. It is a way of knowing and thinking, of seeing the world, and of feeling about people. No one is born a doctor, and the long road to becoming one requires unrelenting study, discipline, and the cultivation of unique talents and skills. But whatever the domain of medical pursuit and however removed from the bedside one's work may ultimately be, its ethos and raison d'être stem from that one enduring relationship: physician and patient.
In our time, this most personal of human services has burgeoned into a $2.5 trillion enterprise employing 1 in 10 Americans. It is a growth propelled by the endless frontier of medical discovery, translating into better ways to care for people. In that sense, a medical career is the intellectual journey of a lifetime. In a field where the sands shift so quickly and one technology is swept away by another, medical school is not about teaching you all the facts you'll ever need to know. Rather, it is the place in which students are slowly converted from laypeople into doctors.
This conversion takes time, with and beyond the books, journals, and professorial pronouncements. Ultimately, one becomes a doctor from an immersion in the unpredictable, varied, and complex ways in which patients fall ill and the momentous efforts of people and technology to make them well. It comes from learning the secrets of the body, the passages of life from birth to death, the tortured times and the peaceful times of human souls, and the uplifting (and carefully harnessed) power of the physician to make a difference every step along the way. For the best of students, by the time they walk across the stage and accept their medical diploma, doctor hood has seeped into the marrow of their bones, the depth of their hearts. Whatever their chosen line of work, they will always see the world through the lens of a doctor.
That lens is broad. Medicine embraces a continuum of knowledge and practice from the micro to the macro level-from the medical scientist in the laboratory, to the doctor at the bedside, to the public health specialist tracking down the latest epidemic anywhere in the world. And along that broad spectrum, one can carve out a professional life of research, teaching, practice or administration-or some combination of all four. There is a place for generalists and specialists, writers and policy wonks, computer jocks and business gurus-all part of a medical community doing something that is in its ultimate purpose about helping another human being.
That the profession helps human beings in a profound and measurable way is in fact why young people dream of being a doctor, and it is the single most common reason medical school applicants give for pursing a medical career. Indeed, it is that perspective that ultimately overrides some of the negative sides of a career in medicine, which in today's world can discourage even the strongest hearted premed. For medicine as we know it today brings its own set of hassles: managed care, increasing government regulations, and malpractice premiums (and massive malpractice awards), on top of discouraging medical school debt averaging more than $156,000 at a time when physicians' incomes are relatively stagnant.
Although there are two applicants for every medical school slot, and the quality of prospective students is thought to be as good as ever, there is widespread belief amongmedical school educators that because of these strains, fewer students are interested in applying to medical school now than a decade ago, a phenomenon masked by the dramatic increase in female applicants. But the reality is that no profession-and nothing worth pursuing in life-is free from its own set of hassles. The reward-to-hassle ratio is what counts. It is something each prospective doctor must sort out for himself or herself.
And the rewards of today's medicine are many. The expanding knowledge base is truly compelling and ever changing to the betterment of patient and doctor. There is virtually no illness we cannot make better, if not cure, and with improved drugs and technology and emerging knowledge of human genomes, we see more tailored treatment of individual patients with better results. As for the doctor's personal life, the hours today are more reasonable and controllable than in the past. The solo doc is becoming a rare breed; large group practices and clinics enable medical practitioners to escape the direct brunt of administrative hassles while at the same time gaining camaraderie and an enriched practice environment. Medicine is a tough and fulfilling career, immutably purpose driven, value laden, intellectually stimulating, and emotionally gratifying. But it is a profession that demands the right stuff of those who serve. Certain deeply held personal qualities are essential; without them, from my perspective as a former medical school dean, students quite simply need not apply. Think hard about them, for they are the essence of the art and the science of being a doctor.
Compassion and generosity. Kindness goes beyond "bedside manner." It is reflected in generosity of time and self, and sensitivity to the unique circumstance of any given situation. Making an extra stop by the room of a lonely patient; giving a worried family member your home phone number; being calm and measured with an ornery, angry, or noncompliant patient. Sickness can bring out the best in people but also the worst, and a physician can lighten a patient's load by being a source of hope, caring, and cheerleading-along with providing technical expertise.
Hard work and grit. It takes a lot of stamina to be part of a world that is always on call in some fashion. The stress might come from a rather mundane struggle with an insurance company for an extra day in the hospital or a needed MRI, or from perseverance against an engulfing bureaucracy. But stress most especially comes from the challenge of caring for the very sick. This demands the courage to make tough medical decisions and, in the face of risk and uncertainty, to proceed with a risky operation or embark on a drastic course of medical therapy. It takes grit to confront one's inevitable failures and learn from them-without becoming timid because of them. In their hearts, doctors must live with the confidence that at the end of the day, they did the best they could, and tirelessly so.
Scholarship and good sense. With medical practice reborn almost every day in new knowledge and emerging technology, new approaches are an essential part of medicine, disseminated in hospital corridors, medical rounds, mortality and morbidity conferences, journal clubs, and national medical gatherings. The wise and learned physicians are those who can sift through the flood of new knowledge and the latest evidence to make it apply to any given patient. That's why we teach medicine at the bedside and through individual case studies of real people. And that's why we respect reasoned judgment that often comes out with different advice. Should that 30-year-old woman with a newly discovered benign heart tumor have prompt heart surgery, as is the practice? Of course-but she is six months pregnant and, with surgery, risks losing the baby, so dare we wait? The PSA is intermittently elevated in a 55-year-old man. Do you watch, or do you biopsy? Yes, a lumpectomy is the conventional wisdom for this precancerous change detected by mammogram, but this patient wants a mastectomy as an alternative because she has a breast cancer gene running through her family. Do we go along? The hyperactive child is driving his family to distraction with behaviors that another family could manage better. Do you medicate?