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.

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.