This piece is part of in-Training Mental Health Week.
I can finally say I’m in my last year of medical school. It has been a bumpy ride, but only one clerkship, a research project and an OSCE separate me from graduating. I remember receiving my acceptance letter eight years ago. Thinking back to those days, neither vocation nor sentiment were on my mind. I don’t consider myself someone who had a particular passion for medicine. My father is a diplomat and my mother a public servant. The closest my family had come to working in a hospital was my grandfather, who installed oxygen pipes in operating rooms. I stumbled upon medicine, and medicine stumbled upon me. My vocation is something that I’ve nurtured over the years, watered by the many inspiring people I’ve met in my journey, and pruned by all the pain and dissatisfaction I vow to avoid inflicting as a physician. I am grateful to have fallen in love with such a noble pursuit. But when I look back to the road that led me here, I feel a pang of regret. Not because of the sacrifices I made, but because the way I chose to live them.
Medical school was not what I expected. In Spain, our program is six years long: two dedicated to the basic sciences, one transitional year and three clinical years. Admission is straight from high school, with applications graded solely on academic performance. Those with the highest marks get in, and I was one of those “high achievers.” I was lucky; my father’s job as a diplomat offered me the luxury of excellent schooling. I had no need to prove empathy, resilience or even interest in the pursuit of medicine; being the quiet diligent student in the front row was more than enough.
My first few months were filled with the promise and excitement of college life: of self-discovery; of parties and exams; of friendships and romances. I felt the world opening up around me. And for a while, it stayed open. I recall that year fondly. The lazy afternoons playing cards in the cafeteria, my first boyish crushes, the quiet trepidation of stepping into the dissection lab for the first time… I was unaware of what I had gotten myself into, but I was enjoying it. After all, biology and philosophy had been my favorite subjects in high school. Medicine seemed like a good fit, the intersection between the messiness of human life and the sturdiness of modern science.
Second year arrived, and with it the toughest subject in our school: anatomy. Infamous for weeding out the “weaker” students, we had all heard the horror stories. I paid little heed, too busy discovering the pleasures of university life. When finals came, I studied, and failed. And then failed again. Fear made me begin to skip classes and even exams, and I was held back a year. My classmates were replaced by strangers, and my friends moved on to the far away world of the hospital. I felt alone. The openness of college was replaced by deadlines and exam dates. Stuck in the hamster’s spinning wheel, I had direction but not purpose.
Instead of facing my failures, I channeled my anger and frustration into student representation. Nights fretting over the next exam turned into endless meetings, projects and emails. And for a while, it worked. I found meaning in the work that I had not in my classes. Cell membranes and tendons were too abstract, too removed from the world of medicine. Fighting for better classes and fairer exams was not. Not only did I sublimate my feelings of failure into activism, it gave me an excuse. I wasn’t failing because of me, I was failing because of our subpar education. And while I was partly right, I was also very wrong.
Being held back was eventually replaced with the very real possibility of being kicked out. Student representation was no longer able to shield me from reality. “I know it’s tough to swallow, but you have to study to pass, not to learn,” I was told. So I changed. I abandoned the meetings and emails. Medical school became a crucible, my passion smelted into pure survival instinct, all else discarded as slag. Becoming a good doctor was no longer on my mind. Textbooks and Medscape gave way to high-yield notes and exams from past years. Memorizing the nigrostriatal pathway had less to do with understanding how to help my patients with Parkinson’s disease than with passing neuroanatomy. And pass I did.
I limped from subject to subject, until I arrived unceremoniously at the end of my third year. The worst was over. I was no longer on the cusp of being expelled. I had survived. And all that was left before me were the “best years” of medical school, the clinical years. Textbooks would give way to patients, diseases and the heroic world of medicine.
I remember asking a fellow upperclassman for advice during clerkships. Her words stuck with me: “take your closest friends, put them in a shell, and don’t look back.” In my naiveté I rejected the idea. Medicine is built upon helping others, cooperating for the greater good of our patients. How can I become a good doctor if to do so I must reject the basis of our craft? The very notion disgusted me. I promised myself that I would avoid that cynicism; I would be different.
The clinical years started, and I was finally learning about medicine. Not cell membranes, but diseases and cures. Most of our clerkships consisted of glorified observerships, but I cherished the contact with patients. The exams were tough, yet nothing compared to what I had gone through. “Maybe this is why they were so tough on us,” I thought. I soon settled into a routine, sliding from exam to exam and clerkship to clerkship. I kept my friends close while my classmates drifted away. When the passing mark depends on how well your colleagues score, you start to see them as rivals. Why should I help them? What do I gain in return? Cooperation was substituted by suspicion. And it helped me succeed.
My sixth year and final year began with a bumpy start. While previous clerkships had always been second in importance to exams, this year it was all about rotations. “You’ll be treated as interns,” they told us. And they were right. It’s easy to avoid bullying when doctors ignore you; not so much when you’re supposed to be “one of the team.” It took me several months to recover from that first clerkship, but I survived. I had become an expert at distancing myself. Surviving rotations was not that much different from surviving exams. All it took was strengthening that shell and powering through.
Christmas break came around, and with it the prospect of graduating in a few short months. I did not feel excited or hopeful. I felt empty, even fearful of what residency would hold. Something was missing. That’s when the realization hit me: I had taken my friend’s advice. I had cut myself off from the things that gave me meaning as a way to defend myself. Instead of flourishing, I had concentrated on surviving. And I had done a good job. But it had left me wanting. While I now knew how to treat a plethora of diseases both common and rare, I had forgotten why it was worth treating them in the first place. Delayed gratification had transformed into delayed growth. The true tragedy of our education is not its lackluster quality or even the institutional hazing we endure, but the sundering of medicine and meaning.
Marcus Aurelius wrote in Meditations: “(…) people cut themselves off — through hatred, through rejection, and don’t realize that they’re cutting themselves off from the whole civic enterprise.” Even if we distance ourselves as a way to avoid pain, we unwittingly remove ourselves from the things that give us meaning. I still struggle to separate my own cowardice from the shortcomings of our education. But with depression and even suicide among medical students on the rise, we must reflect on the type of culture we are imposing. How can we expect to care for our patients if in the process we are forced to hurt ourselves?
In a little over a year, I’ll be a fully-fledged intern. I will have the privilege and the burden of treating my fellow man. In the past months I have found passion and meaning in medical education, in ensuring no other student has to go through what I did. But is that enough to be a good doctor? Why does medicine hold meaning to me? What does being me mean? These are questions I have yet to find answers to. With the ice age of medical school thawing, I recall the lyrics of St. Vincent’s song “Ice Age:” the answer is close to my bones, and far from my shell.
I do not regret choosing medicine. But I do regret living these years bereft of purpose. Moving forward into residency, I am inspired by Paul Kalanithi’s reflections. Paul was undergoing his final years of residency training when he was diagnosed with stage IV lung cancer. Uncompromising in his mission, Paul chose to dedicate his last months to the search of meaning. His words reminded me that there is more to a patient’s disease and suffering than symptoms and drugs. That in helping my patients find meaning in their journey, I can find meaning too.