Medicine: A Physician's Lament

The scene is all too familiar. I have witnessed it--and been a participant--more times than I care to remember: a small team of physicians and students on rounds stops at the door of a patient in the last stages of a disease that has eluded all efforts at a cure. After an awkward hesitation, the senior member turns to the others and says, "She's probably very tired and needs her rest. It's better not to disturb her. Let's just go ahead and see how yesterday's colectomy is doing." The others nod, and they move on to the next room.

Every one of the group knows what has just transpired. The students have already begun to understand that modern medicine is action, that its excitement comes from the challenge to intellect, to technological skills, even to personal daring. The greatest victories go to those who diagnose brilliantly, who are undaunted by the most intimidating confrontations with disease, so long as there is a possibility of cure or at least improvement. These are the biomedical gladiators, and their arena is the hospital. Unlike the gladiators of ancient Rome, they always win. Well, almost always--and only for a while.

When there is no victory, however, the challenge is gone, and most lose interest. Worse yet, they have suffered one of their rare defeats, and they handle it badly. They were not chosen to be defeated, and they are not trained to deal with it. They have been trained for the certainty that theirs is a noble war against death.

It begins with the selection process. Medical school admissions committees look for winners: the highest GPAs, the highest scores on the Medical College Admissions Test, the most glowing reports about undergraduate achievements. They like to see stratospheric numbers and florid adjectives. In view of this emphasis, it is a wonder that they manage to admit as many idealistic young people to the profession as they do. But there are not enough, and every one of these students wants to be a man or woman who knows how to triumph over great odds. When the time comes to lose, as it inevitably must, doctors will too often turn away from the evidence of their perceived failure because they don't know how to behave when faced with it. Few will think to hold a dying woman's hand. They will move on to the colectomy in the next room.

The faults in the selection process are compounded by the faults in training. Today's medical or surgical residencies are like years on end of Marine boot camp, where the values of the group are instilled at the expense of the values brought to the experience by each individual entering it. In the presence of teachers who exemplify the fighter-pilot mentality of success in the face of mortal danger, the idealism and even the humanity become imperiled. Too often, they are leached out in the long indoctrination. The best become like their teachers: they worship at the shrine of scientific objectivity, and they wrap themselves in a mantle of depersonalization that allows them to carry on despite the carnage around them--all in the name of victory over death.