Medicine as a Vocation

“Hey, doc, come over here!” the patient shouts at me and gestures with a
quick wave of his hand as I walk by his room. “I need to show you
something. Take a look at this.”

Without waiting for me to ask him what is wrong, he takes out his member
and testicles and points at them.

“One of my testicles is swollen. Look! And it’s painful, doc. There’s this
shooting pain going up into my stomach. I feel nauseous. Can you get me
something for the pain?”

I look at his testicles and feel both of them with my gloved hand. One is
certainly larger than the other and the patient winces in pain when I touch
them. Though it is close to the end of the day, perhaps ten minutes or so
before I sign out to the nighttime physician, I run through the possible
diagnoses:

testicular torsion

(the testicle twists on itself, reducing blood supply and causing intense
pain and eventual infarction of the testicle),

epididymitis

(an inflammation of a certain part of the testicle usually caused by a
sexually transmitted disease), a varicocele (the
veins of the testicles enlarge due to malfunction of valves within the
veins, causing increased pressure and pain), and other, less common
pathologies.

At this point, the best next step is to get an ultrasound of the
scrotum. This imaging study, which is fairly quick and cheap, gives the
physician a sense of the pathological process. Of course, this has to be
ordered rapidly because if the patient does have testicular torsion, he
needs to be seen immediately by a urologist.

After examining the patient, ordering the test, and calling down to the
ultrasound technician to make sure the patient had the imaging study done,
it is time for sign-out. But I am in a bit of a bind. It is my
responsibility to make sure the patient gets the treatment he needs, but I
also have plans with a couple of friends all the way across town. If I
leave now, I can make it but will surely be late. If I wait for the study,
I will never make it.

I stop by the night physician’s room and let her know that it will be a
little bit of time before I sign out because I’m going to follow up on this
study. She, understanding my conundrum, tells me to leave and kindly
volunteers to take over. Frequently, residents cover for each other in
these situations, for we know, given our hectic schedules, how hard it can be
to find time to keep up with friends, date, and attend weddings, religious
ceremonies or graduations. I jet out of the hospital and just make the
crosstown bus in order to show up twenty minutes late.

At the bar my friends and I discuss our respective days at work. And then
comes the dreaded question, directed at me: “How was your day?”

I pause as I do when people ask me this question, not because I don’t know
what to say, but because there is so much to say I really don’t know where
to begin or what is appropriate. Do I tell them how only an hour ago I was
examining another man’s penis? Do I tell them about the patient I admitted
to the hospital and watched die over the course of five days because his
metastatic cancer was so bad that there were no treatment options? How
about the time a patient walked into the hallway, pulled his pants down,
and pooped on the floor by the nurse’s station?

If I’m honest about the events of my day, I now know the look I’ll receive
in return: the eyes widen, the eyebrows go up, the mouth twists in slight
disgust and the jaw drops ever so slightly. “Why,” their shocked facial
expressions seem to say, “are you telling me this?” The problem is that
these stories and experiences not only are a part of work; they become a
regular occurrence and a part of life. Resident hours are so long and so
intense that, frequently, there isn’t much else to talk about. Anything
outside of the hospital feels unnatural to residents; we no longer fit in.
Our singular experiences mark us in a sometimes Hester Prynne-like way among our
friends and significant others outside of medicine.

Sometimes, too, we mark ourselves not outwardly but inwardly. When I am
with friends at a bar or at an apartment sipping on a beer, it will
suddenly occur to me that three hours prior, a patient was vomiting on me or
dying

as I pumped on his chest
. The juxtaposition between these two very close moments in time is
bizarre.

But even beyond these occasional strange realizations and awkward
interactions is something much more expected. When I describe to acquaintances what
neurologists do, a typical response goes something like
this: “My grandfather is losing his short-term memory — could this be
Alzheimer’s?” Or, “my grandmother has Alzheimer’s, are there new
discoveries being made on how to cure it?” Some of this is about making
conversation related to my job. However, what becomes clear is that you cannot
escape the profession. For better and for worse, it

follows the doctor everywhere
.

~

In February 2017, Dr. Farr Curlin, the Josiah C. Trent Professor of
Medical Humanities at Duke University,

wrote a wonderful essay in Big Questions Online
 about medicine, titled “What Does It Mean to Have a Calling to Medicine?”
In it, he explains his hopes that young physicians see medicine as a
vocation: “To practice medicine as a vocation is very different [from other
professions]; it means putting oneself forward not merely as a physician
but in order to become a physician.” And becoming a physician takes “a lifetime of effort.” He compares it to the theological
concept of vocation, in which one is summoned or called by God to a certain
task. His purpose, I think, is not to portray doctors as gods or medicine
as the holiest of professions, but to make clear how absolutely consuming
medicine is if taken seriously.

To practice medicine as if it were just another 9-to-5, Dr. Curlin
observes, “is akin to play-acting.” One attempts to keep the role at a
distance. This is a fool’s errand, as no serious physician can manage it. Any serious approach to the profession necessarily leads to a consuming embrace. I think even of physicians I know who
have reached the highest levels of their field, but who still respond to
patients’ emails at night after they’ve come home from work; they must be
available by phone day and night when they’re on call; they still have to
keep up with new research, which they read on their own time; and many even
do medical research outside of work hours. This is not to mention the incredible and unsettling statistic that physicians have one of the highest suicide rates of any profession, a rate more than twice that of the general population.

Anton Chekhov via Wikimedia

Dr. Siddhartha Mukherjee, a physician-writer, has considered this dilemma,
too. In a stunning essay for The New Yorker,

he writes about Anton Chekhov
, the great Russian playwright. Chekhov gave up his medical practice to
travel to Sakhalin Island, a Russian island in the North Pacific Ocean. At
the time it was a penal colony, packed with the destitute and hardened
criminals of the Russian Empire. Why would Chekhov travel here? What
purpose did this trip serve? Mukherjee argues that Chekhov used Sakhalin
“as an antidote.” Chekhov, he claims, had become desensitized to his life
as a physician, numb to human suffering as well as to the greater corrupt
political struggle in Russia. And it is here, among the detritus of society, where Chekhov discovered sensitivity. This story poses the question faced by all physicians, Mukherjee writes: “What will move me
beyond this state of anesthesia? How will I counteract the lassitude that
creeps over my soul?”

In one sense, Mukherjee’s essay serves the purpose of encouraging the discouraged,
angry, numb physicians. But in another sense it illustrates the point that
medicine is a vocation. When patients’ suffering becomes just another task to
deal with, physicians falter not just as physicians but as people. Medicine
reaches beyond its worker bees and into the hive. It claims
physicians as human beings. It claims a part of their souls.

This is not all bad or all good. But it is nearly impossible to
dissociate the personal life from the professional life as a physician.
Medicine practiced well must be a vocation.

physicians, patients, and intellectual triage

Please, please read this fascinating essay by Maria Bustillos about her daughter’s diagnosis of MS — and how doctors can become blind to some highly promising forms of treatment. The problem? The belief, drilled into doctors and scientists at every stage of their education, that double-blind randomized tests are not just the gold standard for scientific evidence but the only evidence worth consulting. One of the consequences of that belief: that diet-based treatments never get serious considerations, because they can’t be tested blindly. People always know what they’re eating.

See this passage, which refers to Carmen’s doctor as “Dr. F.”:

In any case, the question of absolute “proof” is of no interest to me. We are in no position to wait for absolute anything. We need help now. And incontrovertibly, there is evidence — not proof, but real evidence, published in a score of leading academic journals — that animal fat makes MS patients worse. It is very clearly something to avoid. In my view, which is the view of a highly motivated layperson whose livelihood is, coincidentally, based in doing careful research, there is not the remotest question that impaired lipid metabolism plays a significant role in the progression of MS. Nobody understands exactly how it works, just yet, but if I were a neurologist myself, I would certainly be telling my patients, listen, you! — just in case, now. Please stick to a vegan plus fish diet, given that the cost-benefit ratio is so incredibly lopsided in your favor. There’s no risk to you. The potential benefit is that you stay well.

But Dr. F, who is a scientist, and moreover one charged with looking after people with MS, is advising not only against dieting, but is literally telling someone (Carmen!) who has MS, yes, if you like butter, you should “enjoy” it, even though there is real live evidence that it might permanently harm you, but not proof, you know.

In this way, Dr. F. illustrates exactly what has gone wrong with so much of American medicine, and indeed with American society in general. I know that sounds ridiculous, like hyperbole, but I mean it quite literally. Dr. F. made no attempt to learn about or explain how, if saturated fat is not harmful, Swank, and now Jelinek, could have arrived at their conclusions, though she cannot prove that saturated fat isn’t harmful to someone with MS. The deficiency in Dr. F.’s reasoning is not scientific: it’s more like a rhetorical deficiency, of trading a degraded notion of “proof” for meaning, with potentially catastrophic results. Dr. F. may be a good scientist, but she is a terrible logician.

I might say, rather than “terrible logician,” Dr. F. is someone who is a poor reasoner — who has made herself a poor reasoner by dividing the world into things that are proven and all other things, and then assuming that there’s no way to distinguish among all those “other things.”

You can see how this happens: the field of medicine is moving so quickly, with new papers coming out every day (and being retracted every other day), that Dr. F. is just doing intellectual triage. The firehose of information becomes manageable if you just stick to things that are proven. But as Bustillos says, people like Carmen don’t have that luxury.

What an odd situation. We have never had such powerful medicine; and yet it has never been more necessary for sick people to learn to manage their own treatment.

Revisiting The House of God

Dr. Stephen Bergman, a psychiatrist, published his now-famous satirical novel The House of God under the pseudonym Samuel Shem in August 1978. The book’s protagonist, a young intern, describes the emotional and physical difficulties during the first year of residency. With more than two million copies sold, the work is something of a classic within the
medical profession.

Even in medical school, before we started our clinical rotations during our third year, some of my
friends and professors recommended I read the novel, so I borrowed it from a fellow student. I enjoyed it but couldn’t fully identify with the
characters in the story, which dealt with the hardships of residency: terrible hours, unsympathetic attending physicians, obstreperous and ornery patients, horrible deaths, and flailing personal relationships outside of the hospital because of the amount of time spent inside it. As a student, I hadn’t yet seen
these things and from the outside this all seemed unrealistic: How, I asked myself, could this even be close to the reality of a modern academic hospital?

Now that I am through my third and fourth years of medical school as well as my first year of residency I have re-read the book, and I thought it would be
interesting to reconsider my initial impression. Indeed, the novel is so much more relevant to me now. In order to illustrate this, it is worth looking at
just a few passages.

I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my
ossicles for twelve hours. I hadn’t had time for breakfast, lunch, or dinner, and there was still more work to do. I hadn’t even had time for the toilet,
for each time I’d gone in, the grim beeper had routed me out. I felt discouraged, worn. (p. 41)

Though slightly hyperbolic, all this is scarily familiar to me. On some days there is so much work to do that one doesn’t really have time to sit down and
eat. Or, when one does finally have a spare moment (after 6 or 7 hours of running around), animal instincts take over and without being cognizant of
it one ravenously attacks any food available. Some of us stick granola bars in our white coat pockets to prevent this sudden and unfettered hunger attack
but even this is just enough to make us want more. Occasionally, the issue is that one forgets to eat and when we smell the trays of food being
delivered to hospital rooms during lunchtime, our intestines do somersaults, squeeze, shiver, and groan as we are reminded of our baser needs. We experience
pangs of hunger that occur throughout the day because meals, and even glasses of water if one has time for them, are far apart. I have, in multiple instances, come home at night or in the morning and stood for a moment in the kitchen while having an internal debate with myself: Am I more tired or
hungry?

And Shem’s line about the “grim beeper” made me laugh out loud. I remember twice walking into the bathroom to answer the call of nature, when suddenly the shrill sound from my pager or phone prompts me to abort the mission, walk out, and
answer the other call.

The talk was, on the part of the doctors, all medicine….

The accuracy of this is stunning. When residents get together or when we have a spare moment to chat at work, we don’t usually talk about politics or
friendships or relationships so much as we talk about medical stories. We trade tales of difficult procedures or illnesses or we tell hilarious medical jokes. Friends who spend time with us
outside of the hospital are shocked at how much we speak about work with each other. But a resident’s life revolves around the hospital. We (almost)
literally reside at the hospital and the eventful aspects of our lives usually occur in the healthcare setting. As one can see from even a quick glance at
some posts on this blog, medicine is filled with human drama, humor, sickness, death, and life. How do we avoid talking about all that in our spare time?

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man
With Agonal Respirations die that night, his kidney consult, a House red-hot Slurper named Mickey who’d been a football star in college, came along, went
to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying…. Mickey called a
cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful
death. (p. 245)

These can be traumatic moments, indeed (I have written about coding patients herehere, and here). Shem’s point is that we in the hospital sometimes do
chest compressions on patients we surely will not be able to resuscitate or, if they are resuscitated, will be dependent on a ventilator and unconscious
for the remainder of their days. Do we try to revive a 90-year-old with metastatic cancer to the spine and brain? Or do we try instead to make the patient as comfortable as possible?
From the patient’s side (and the patient’s family’s side) the difficulty, which seems insurmountable, is in accepting the end. For most physicians, like the
narrator of The House of God, the difficulty lies in cracking ribs and sending electrical shocks through someone’s body with no clear purpose. In fact, we
frequently ask families to let us make their loved ones comfortable, at least, before they pass away. But that is not always the decision that is made.
And in the passage above Shem satirically chides those who believe the best course is always to be as aggressive as possible.

Eat My Dust Eddie, being run ragged in the death-house, the MICU [Medical Intensive Care Unit], looked awful, and was talking about his previous night on
call: “I was admitting my sixth cardiac arrest and I got this call from the E.W. — Hooper, it was you — saying that there was a guy down there who’d
arrested and you were thinking of sending him to me if he survived. I hung up the phone, got down on my knees, and prayed: Please, God, kill that guy! I
was on my knees, I mean ON MY KNEES!” (p. 126) 

My colleagues and I have never wished that anyone would die. But, undoubtedly, we all identify with the feeling of being overwhelmed. When you’re exhausted
and still admitting patient after patient and trying to work them up for a new diagnosis while also taking care of other patients on the service, writing notes,
fielding pages or phone calls from nurses, drawing blood, and doing CPR, there are moments when it feels as if there is no more time or effort left to give.
You are working with rope with no slack or trying desperately to tread water. This is especially true in a place like the Intensive Care Unit, where patients are sicker
and require closer monitoring. During those moments, we beseech the hospital gods: “please, no more admissions, please no more.” Or, “please don’t let
anyone get sicker than they are.” It’s not every day one feels this way, but it is often enough that the sentiment is familiar.

*   *   *

When The House of God was first published it was not received well by Dr. Bergman’s colleagues and peers. As he tells it,

… my book The House of God enraged many among the older
generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None
of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

Thus, the book is not only a brilliant and witty piece of satirical literature, it is also a “fiction of resistance,” as Bergman describes it. Its most sinister and clueless
characters are the ones in charge. And in many cases their worship at the altar of medicine and science damages their relationships with patients,
residents, or each other.

Much has been written about this aspect of the book in recent years: Dr. Howard Brody of the University of Texas Medical Branch

wrote about its relevance in the American Medical Association’s Journal of Ethics in 2011
. Dr. Suzanne Koven, a primary care physician,

interviewed Dr. Bergman about the book for the Boston Globe in 2013
. Dr. Howard Markel, a professor of pediatrics, psychiatry, and the history of medicine at the University of Michigan, discussed the book in a piece for the New York Times in 2009.

The reason for this interest may have something to do with a story Bergman tells in his own 2012 piece for The Atlantic:

And then one day I got a letter forwarded from my publisher, which included the line:
“I’m on call in a V.A. Hospital in Tulsa, and if it weren’t for your book I’d kill myself.”
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey
of speaking out, around the world, about resisting the inhumanity of medical training.

But the culture in medicine has changed dramatically since this book was written. Institutions are far more humane than they once were. Nevertheless, what we see and how much we need to see cannot change. Doctors ought to be exposed to a wide range of pathology; they
must be exposed to death. This is how one learns to be a great doctor, to diagnose obscure diseases, to treat common diseases successfully, and to save
lives during a hectic code in the hospital.

No matter how authority figures treat residents, Bergman’s book will always be precious to future generations of doctors. Like any great novel it identifies common yet significant human experiences. The author tells us, as it were, that “yes, I know
exactly what this is like and I laughed at the same things you did. I made the same mistakes. I had the same
difficulties.” Such commiseration ameliorates that unsettling feeling residents experience: the feeling that the hospital is a rabbit hole
that spirals into a detached and harrowing yet hilarious world. And, because of The House of God, there will always be a shared understanding
among residents and readers of the triumphs and tragedies accompanied by this feeling.

The Purpose of Medicine

American medicine is not well. Though it remains the most widely respected of professions, though it has never been more competent technically, it is in
trouble, both from without and from within.
—Dr. Leon R. Kass

As a newly minted medical school graduate, I am suddenly faced with much more responsibility. Now I must write prescriptions for patients, write notes
on patients, and know what to do during an emergency. It is all very daunting. While anxious and excited about these new responsibilities, I am also
confused about what I’m doing it all for.

I don’t mean that I’m confused about why I chose medicine. True, medical school was incredibly difficult, but there will be many rewards down the road. I
mean to ask: What is the purpose of medicine? It is queer that one should spend four years learning medicine and not know one’s purpose. But no one ever
discussed this question in medical school. Now, after graduation, the question’s importance is suddenly apparent. My future actions depend on the answer to
it.

Some answers are implied during our schooling. The purpose of medicine that seems obvious is to cure the patient of disease. After all, this is
why patients come to the doctor. But sometimes, we also attempt to make people happy. I’ve seen patients receive IV fluids because it will
“make them feel like they’re getting treatment.” I’ve seen children receive antibiotics even when they didn’t need them, simply because the parents wanted
something done for their children. I’ve also seen a patient receive a “therapeutic” EKG — his chest hurt and despite the fact that there was no way he was
having a heart attack, he received an EKG to “calm him down.” The goals of medicine, according to my own limited experience then, are at least twofold: the
elimination of disease and, more broadly, patient satisfaction even when it has nothing to do with disease.

Dr. Leon Kass, a teacher and bioethicist trained as a physician (and a New Atlantis contributor), wrote about the purpose of medicine in the 1975 essay “Regarding the End of Medicine and the Pursuit of Health”
in The Public Interest (available here as a PDF). Though written forty years ago this summer, the essay is as relevant and necessary as ever. I’ll highlight some of Kass’s major points to help us think through my
question about medicine’s purpose.

The fact that the purpose of the medical profession is not often considered is, Kass points out, deeply troubling. Indeed, without an
answer to the question, Kass writes, “medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a
technician and engineer of the body, a scalpel for hire, selling his services upon demand.” This would spell the end of medicine, Kass believes — “there
will be an end to medicine unless there remains an end for medicine.”

Kass proceeds to tackle the issue by critiquing some of the goals of medicine that people sometimes assume. Happiness, he argues, should not be the
purpose of medicine. Kass offers some examples of physicians attempting to make patients happy: a surgeon might remove a woman’s breast so she can improve her
golf swing, or a family physician might administer amphetamine injections to people who want to
feel good. These interventions are aimed solely at gratification and thus are not even concerned with pathology.

Even the prolongation of life or the prevention of death per se should not be the goal of medicine, Kass argues. This, perhaps, is difficult for us to understand. Indeed,
doctors daily witness death and terminal illness. If we know CPR,
do we withhold it because it’s not our job to prevent death or prolong life? Not at all, but if we believe that the goal of medicine is the
prevention of death, then the logical endpoint of this must be “bodily immortality.” Kass observes that “to be alive and to be healthy
are not the same, though the first is both a condition of the second, and, up to a point, a consequence.”

Anyone’s life can be prolonged now. Machines
breathe for patients. Machines oxygenate patients’ blood. Machines pump blood into the circulatory system. All this occurs regularly in the intensive care unit. But if physicians put patients on these machines indefinitely
solely to keep blood flowing through arteries regardless of the patient’s condition, the mere preservation of life, and by extension the job of medicine,
is meaningless.

The goal of medicine, according to Kass, is the preservation of health. The word “health” in English means “wholeness.” It is derived from the
Old English hal, which is also the origin of “whole.” For Kass “wholeness” involves a “fully formed mature organism … composed of parts. It is a structure and not a
heap.” Additionally, wholeness includes the “working-well of the work done” by a person’s body. Thus, health consists of a proper balance of parts that
make up the whole and the workings of the whole human being. In order to demonstrate his point, Kass takes the example of a squirrel. A healthy squirrel is
not just a squirrel with a normal digestive tract, it is a squirrel who acts and looks like a squirrel. It leaps from tree to tree, runs, gathers, and
buries. All of these characteristics tell us that this is a fully-functioning, whole squirrel—a healthy squirrel. Similarly, a healthy human being acts
and looks like a human being. While this concept may seem vague, Kass’s point is well-taken; a healthy human is “recognizable if not definable.”

A good example of preserving health is the well-child visit in a pediatrician’s office, where physicians check for normal growth and development. This
demonstrates that “health is a good in its own right, not merely a privation of one or all evils.” In other words, pediatricians don’t just see children
who are sick (though they do that, too); they also see children who are healthy. And in doing so they help make sure that these children remain healthy. Family medicine physicians do something similar with adults. They see their patients on a regular basis
to ensure that patients are exercising, eating right, and have no abnormal blood counts or cholesterol numbers, and that they are otherwise doing well.

Check-ups like these are as important as giving a patient antibiotics for pneumonia. Medicine involves figuring out how to maintain the excellent functioning of a human
being. It necessarily includes what today we call preventive medicine: vaccines, cessation of smoking, a healthy diet, an active lifestyle. This view of medicine necessarily involves the patient as a partner to the physician: both work together to help maintain the health of the patient.

Many of the things we expect from medicine today do not fall under Kass’s definition of health. The injection of Botox to make one look younger, for example, does not
involve health in any way whatsoever. Having wrinkles in one’s face does not affect the excellent functioning of a person. Endocrinologists, plastic
surgeons, psychiatrists, and many other specialists and generalists all deal with patients who request the kinds of procedures that go beyond health. Whether these procedures ought
to be available is a completely separate question from whether these services fall under the purview of the physician. If physicians perform them for
patients, then physicians, I think, become service providers to the highest bidder. They become technicians at the whim of patients. (Kass addressed some of these same themes about the difference between therapy and enhancement in his 2003 New Atlantis essay “Ageless Bodies, Happy Souls.”)

To be sure, Kass’s 1975 essay does not go into the kind of detailed, philosophical argument that we might hope for. Kass himself admits this when he writes,
“large questions still remain” and “I am not seeking a precise definition of health.” But he gives us a basic and firm outline of the purpose of medicine
and we would be remiss if we didn’t study this purpose carefully. Without a purpose,
medicine lacks moral certainty or a soul. None of us, within medicine or without, can afford that.