What is it that doctors like about what they do? Why would someone choose to become a doctor?
And how does a person decide to become a pediatrician instead of an allergist or a surgeon?
I put these questions to thirty doctors I know around the country. Not all of them answered my questions -- one neurosurgeon, for example, wrote back that she would love to answer the questions but wouldn't have time until next year! -- but those who did were wonderful in explaining how they ended up where they are, what aspects of their work intrigue them most, and what challenges and rewards keep them interested, satisfied, and happy.
"I wanted to have a skill," commented one pediatrician, "that would make me useful and productive anywhere in the world." She was majoring in urban studies in the 1970s, a time, she noted, "of tremendous social upheaval on college campuses. I didn't want to have a career that tied me to any existing political or social institution." That's when she decided to become a doctor.
So there she was, pre-med and in her junior year, and she had taken "only horticulture to fulfill my basic science requirements. I set myself to the task of taking all of the required pre-medical courses during the next 2 years," she continued, "and, as luck would have it, my first cousin was then a biophysics major at the same university. In return for debts to me he had incurred during our childhood -- I'd taught him how to cross the street and all of the dirty words I knew! -- he took me under his wing and taught me how to study science."
"I entered medical school with the idea of becoming a family practitioner, again with the idea that this would provide me with the most generalizable skills. I could treat anyone, anywhere, I figured. But, through influences of peers primarily, I began to shed my image of myself as world traveler and began to enjoy the notion of serving a community of people over time -- a community in which I would live and raise a family."
"Because there were no role models for me in family practice at my medical school, I took a month to work with a family practitioner in rural Maine. While I admired this doctor greatly, that experience helped me realize that I was really a city dw eller, and, during that era, family practitioners were almost non-existent in urban areas."
"I did my first pediatric rotation in a large urban children's hospital. I loved everything about it. My patients were cute, their parents cared intensely about their health, the whole family was considered in the care of the patient, and pediatricians were the group of doctors with whom I felt most compatible. Worki ng with kids provides you with a sense of humor, humility, and love that just isn't matched anywhere else in medicine."
A second wonderful pediatrician I know echoed some of these pleasures of caring for children. "Pediatrics," he said, "to my mind, is the most optimistic area of medicine to practice day in and day out."
For him, the road to medicine had been rough-going. "My father was a pediatrician, but I avoided science like the plague all the way through college. Science had never been my forte. I finally realized, though, that I derived the most pleasure fro m working with and helping people, and I had been watching my father enjoy his work for years."
"The courses required for pre-med almost stopped me from progressing further," he said, "but, when I finally got into medical school, the human application made studying enjoyable again. Although the sciences are the basis of medicine, the actual practice of medicine is much more than just science." This point is one that John Duffy makes as well in his new book on the history of American medicine: "Despite all scientific developments and the use of sophisticated instruments and laboratory techniques, medicine is still an art, and much of what a physician does is a matter of judgment (1)." The ancient Greek physician Hippocrates said something similar 2400 years ago: "The art has three factors, the disease, the patient, and physician. The physician is the servant of the art (2)."
In direct contrast to the pediatrician I just described, another doctor I know said he came to medicine because of his interest in science. "I was good in math, physics, and chemistry and went into internal medicine because of its analytical component. My uncle, who was a chemist, convinced me not to work for a large company as he had done. In the 1960s, medicine was a 'cottage industry,' and one could be one's own boss."
Advice and guidance -- from a relative or a colleague or a teacher or a friend -- were cited by many doctors as powerful forces in how they chose their careers. Someone who provided an example often tipped the balance in a specific direction. Frequently, the advice and example came mixed with a key human ingredient -- kindness.
A pediatric pulmonologist (a specialist in lung diseases of children) says he
would never have guessed that he would choose to treat children. "I thought,"
he said, "when I was in medical school in Sri Lanka, that examination of a child
who was at best uncooperative would be next to impossible. But, I was later
assigned to an internship with a pediatrician who changed my entire outlook. He
was a kind, considerate, and understanding person who taught me the art of
examining pediatric patients."
Another doctor who has joint certification in nephrology (the study of the kidneys) and endocrinology (the study of hormones) recalled that "in the 1970s, I was treating a patient for pneumonia. She also had acute renal failure (her kidneys were shutting down). In those days, we didn't draw blood samples as often as we do now, so it was several days before I found out that the patient's serum sodium concentration was at such a low level that the medical books said she should be in a coma. She wasn't comatose: she was fine. I called in a kidney specialist for a consultation. The logic and clarity of his thinking, his gentleness toward me, and his sense of humor led me to associate increasingly with him and his division. Through this association, I met a second doctor who was both a nephrologist and an endocrinologist, was from my home state, and was an avid fisherman (as am I). These two doctors became my friends and mentors."
By the very natures of their specialties, some doctors routinely spend long hours, even most of their
time, in the hospital. Surgeons and gerontologists (those who specialize in the diseases of aging)
are two obvious groups who do this. Other doctors may visit the hospital only rarely. The rest fall
somewhere in between. One doctor, who spends about half his time in the hospital, feels energized
by the "atmosphere, which is charged with illness, fear, and hope." Another says he avoids the hospital "except to see patients, unlike other doctors I know
who 'hang out' there."
For outsiders looking in on the medical profession, perhaps the most daunting consideration is the issue of death: what is it like to watch patients die? "I think," said one doctor, "that one of the most rewarding things in medicine is one that scares most doctors to death, and that is saying, openly, 'look, this has all gone much too far, let's quit,' and we all agree to quit. A patient of mine just died and the whole thing was wonderful. Her family was all around. I tend to know my dying patients and their families pretty well, which is the only thing that makes this possible. When everyone is in agreement, I always make a point of turning off the respirator (or other life support equipment) myself rather than delegating that task. That way, I have the enormity of the decision and its consequences stuffed in my face, and I don't do it lightly. With the patient I just mentioned, I walked into the room just as she was clearly breathing her last. The family members were there in tears and afterward there were smiles of relief all around."
The use of elaborate life-support equipment has created a condition for many patients that allows them to remain alive for a long time but in a way that does not really seem to have much to do with living. The so-called "half-way technologies" that keep people half-way alive have created troubling ethical dilemmas for doctors, patients, and their families. One doctor told me, "I am not fond of 'high tech' stuff for my critically ill patients." Another summed up the situation this way: "What is going on with medicine and causing so much trouble is that we are simply too good, and still we are not good enough."
As with every profession, some people absolutely love what they do and wouldn't change a thing, others are lukewarm about it, and still others say they made the wrong choice. But, as a group, doctors report general satisfaction with their profession. In 1992, in a ranking of 100 jobs, physician stacked up as the third best job in America (3). First in the lineup were biologists, geologists were the next best satisfied, and college math professors came after doctors. Taxi drivers were number 100.
Several doctors felt that one of the real plusses of being a doctor is the opportunity to develop meaningful and lasting relationships with both patients and their families. One described his interactions with patients' families this way: "Once I am convinced the patient is doomed, the next-of-kin become my patients, and I do the best I can to treat their dis-ease." Another said that one of the reasons he likes what he does is because it has allowed him to "cultivate longterm relationships with patients and entire families." A third, who teaches pediatrics to medical students, says she "meets new families every day in the clinic and has known others since their first child was born four, five, or six years ago." She commented that there is simply "nothing that matches the feeling of seeing that little naked newborn and its family grow and change over the years. What luck that I stumbled onto this path."
