Wednesday, January 2, 2019

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.
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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.

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