I’d be the first to admit that I’m a bit of a control freak. Sitting at home, waiting for a friend to respond about tentative plans at an undetermined time can drive me crazy. I’ve been known to walk two or three miles to make sure I’ll get somewhere on time rather than take my chances with public transportation. The most stressful part of the medical school application process for me was the last phase, when there was nothing I could do except wait to hear back. I feel most content when I know there are concrete actions I can take to influence an outcome I care about.
I’m willing to bet that I’m not the only medical student who feels this way. In fact, I’ve been amused to discover that I may fall more towards the easygoing end of the spectrum among the med student population. This makes perfect sense considering the path we all took to get here. A healthy (or slightly unhealthy) dose of neuroticism is an adaptive trait for a process involving years of rigorous pre-med courses, a high-stakes standardized test and an almost comically long and complex set of application requirements. While the final verdict is out of our hands, each step on the road to medical school can provide that burst of satisfaction that comes with completing a task you have control over.
I would argue that this continues to hold true during the preclinical years of medical school. At the beginning of first year, I relished the thought that I could plan my own days again after two years of being at the mercy of an unpredictable boss. While the never-ending cycle of exams certainly presents its own stresses, we still retain control over the outcomes we care about. We can decide when, where and how to study and how to fill our time when we’re not studying. While we don’t have control over what will be tested on the exam, we at least have the assurance that each question will have one right answer and that, if we put in the work, we will know what most of them are.
Working at the Veterans Administration as a nursing assistant this past summer gave me a glimpse of how dramatically this will change once we enter clinical rotations. I spent my summer on a general medicine floor and helped care for patients with a wide variety of problems. The one constant, however, was that many of the outcomes that mattered were beyond the medical team’s control.
There was a patient, barely older than I, suffering from severe post-traumatic stress disorder and multiple substance use disorders. Everyone was sure he would relapse the second he was out of the hospital. Another patient, who struggled with heroin use and credited the hospital staff with saving her life, seemed motivated to stick with treatment. Still, I have no way of knowing or influencing what happened to her after she was discharged. I saw a patient die in one of our hospice rooms due to complications from an elective surgery. I helped care for another hospice patient who seemed long past ready to die but likely still had many months to live. He was in constant pain with his faculties and the last bit of his independence slipping away. In these cases, the nurses, doctors and staff did everything they could to help, but they had very little control over the ultimate outcomes.
I think many of us control freaks might be attracted to medicine not just because of the minutiae of the application process but because the desire for control is deeply embedded in the ethos of the profession — and for good reason. We can give people antibiotics that leave them cured in a few days from something that would otherwise have killed them. We can cut people open and remove a tumor making them sick. As I witnessed over the summer, while people are in the hospital we can exert almost complete control over what they eat, when they sleep and how they go to the bathroom. If we cannot fix the problem ourselves, we can arm our patients with knowledge and guidance that helps them gain control over their depression or diabetes or substance use.
But all too often it is clearly not that simple. Oddly enough for a self-identified control freak, I find myself most drawn to areas of medicine where I would have the least direct control over my patients’ outcomes, such as primary care, addiction medicine and palliative care. I think this is because these are also the areas that would allow me to get to know my patients best as people, to learn what drives their behavior and what makes their lives meaningful. If I’m being honest, it’s probably also because I would derive even more satisfaction from being able to influence the outcome in these gray areas than I would from being able to, say, perform a procedure well.
Regardless of what specialties we end up in, I think all medical students would benefit from more education on how to accept nuance, messiness and lack of control in our professional lives. Perhaps our tests should include some questions without one clear right answer. Maybe we need more opportunities to practice just sitting and listening to a patient instead of trying to identify and solve all their problems. Maybe we need to have a larger discussion about what effective medical care means in an era when people are living longer but too often spend their later years over-medicated and socially isolated. I don’t have any easy answers, but I think it’s clear that we would all do well to learn to embrace uncertainty and lose some control.