Friday Reflection 25: The Advice I’d Like to Give a Student Entering Medical School

EJ was a 32-year-old man with risk factors for HIV infection who presented to the emergency room with two weeks of worsening shortness of breath. When he arrived, he was tachycardic, tachypneic, hypoxic, and his chest x-ray revealed diffuse parenchymal infiltrates consistent with pneumonia.

One of the many privileges of being a physician, and a professor of medicine at a “prestigious” medical school, is getting to talk to young people who are considering a career in medicine. Most often, students are “referred to me” by a parent. The parent will find out what I do, talk to me for long enough that a request will seem neither awkward nor presumptuous, and then ask if I might have time to talk to their child. I’ve never said no. What reliably follows is a conversation with a smart, earnest, mature, and absurdly accomplished young adult. They ask good questions that get at the decisions that are most real to them at the time.

Should I do research this summer or get a job?^[1]

I want to take physics over the summer to free up time in my schedule. Will the admissions committee frown on this?^[2]

What should I major in?^[3]

The student never asks for the advice I want to give. Advice about the bigger picture.

One afternoon, after having had the usual conversation with a young man (who I honestly thought would be wasting his obvious brilliance in a career in medicine), I sat at the table in my office and considered what advice I would give a student if one ever said, “I don’t even know what to ask. What advice do you think is most important?”

I thought I could easily come up with something inspiring. But as I pondered it, all I could think of were the pithy statements that fill white-coat ceremony addresses or the conclusions of personal statements.

“Take care of the patient, not the disease.”

“Combine your love of science and your desire to care for people.”

“The secret of taking care of a patient is caring for the patient.”^[4]

On the verge of giving up, and knowing that nobody was actually ever going to ask for my random musings, I realized that a drawing that hangs in my office pretty well summarizes four pieces of advice I’d like to give. The drawing is a simple yet beautiful piece of art: charcoal on paper, a hand and arm fading out just proximal to the elbow.

The drawing was given to me by EJ, a patient I met during my second clinic of internship. It was 1993 and his primary concern was that he worried that he was infected with HIV. During his first visit he told me his story. After he graduated from high school, he moved to New York City to work on his painting. He spent much of the late 1980s in New York, working on his art, and having some risky sexual encounters. In 1993, he left New York, moved to Boston, and got assigned to me, a new intern, as his new doctor.

After taking his history and doing his physical exam, I recommended HIV testing. “Not going to happen,” was his reply. My argument for early diagnosis and initiation of “cutting edge” HIV therapy went nowhere. It was at this visit that we wrote the script that we acted out every few months for the next three years. Each of our visits would begin with me taking care of any pressing concerns, and end with me recommending HIV testing. He would decline. By my final year of residency, we would both smile when I made the pitch. We had become friends during these visits. I considered the visits unproductive.

I continued to care for him after my residency ended. In November of that next year, he paged me one morning. I could hear his breathlessness over the phone. He told me he had been feeling badly for a week and was now too short of breath to make it through a shower. I met him in the emergency room and presented his history to the resident. In rapid succession he was diagnosed with Pneumocystis carinii pneumonia^[5] and HIV.

This story has a happy ending. EJ was diagnosed with HIV at an opportune time. His pneumonia was treated, and he was started on a regimen including the newly released protease inhibitors. His immune system recovered, his health improved, and he has continued to be a productive artist. Nearly 30 years after we met, he still occasionally sends me photographs of his work.

So back to the drawing: what are its lessons and why should aspiring medical students care? I will address this to the future doctor.

Lesson Number 1: Often, the most important service we provide a patient is not what we think it is.

While caring for EJ, I thought I was failing him. How could I let this man’s disease progress, untreated, for years? But really, unknown to me, we were forming the therapeutic alliance that would enable him to reach out to me, as a trusted confidante, when he was ready, or forced, to face his illness. This lesson remains with me. I am reminded of it every time I abandon my own agenda to meet the needs of a patient. You will begin caring for patients before you have much medical expertise. You are unlikely to make diagnoses that have eluded the more senior members of your team. You do, however, have a great deal to offer.

A few years ago, while I was attending on the general medicine service, I admitted a man who was not only terribly sick but hated doctors with a unique passion. Once he was stable enough to exercise his own will, he informed us that he was leaving the hospital. If he had done this, he would surely have died. The medical student on my service spent hours with this man. Even though this patient would barely speak with me, she found a way to communicate with him. He remained in the hospital for a couple of weeks and left with a management plan that has kept him alive for years. The third-year student saved his life not through great clinical acumen or medical knowledge but through caring commitment.

Lesson Number 2: Much of what you are taught is wrong.

This second lesson might be the most important one. Your most committed and brilliant teachers will teach you things that are later proven wrong. And when I say wrong, I mean wrong. And not wrong at some later time, just wrong. There was a general internist where I did my residency whom I worshiped. He was a great doctor, a committed educator, and just a smart, really good guy. He brought my interviewing and physical examination skills to a whole different level. He taught me how to manage chronic pain and how to counsel patients on sensitive issues. I remain indebted to him and still see him in the way I practice medicine. I also now recognize that some of what he taught me was incorrect.

One thing he taught me was that getting too close to patients was dangerous. He told me to never accept gifts from patients. He had strong arguments for this advice, supported by personal experience.

Six months after EJ’s admission, I took a new job in a new city. When I told EJ that I was moving, we hugged and he told me that he had a painting he wanted to give me. Remembering the advice of my mentor, I told EJ that I could not accept it as a gift, and insisted that I pay for the painting. I am embarrassed telling this story. Here was a person attempting to say a heartfelt thank you with a nonmonetary, personal creation, and I refused his gift. I was thrilled, years later, when I came home to a poster tube containing the drawing that hangs in my office. EJ had given me a second chance to accept a gift—in a way that I could not refuse.

Someone once said that as we get older more of our patients become friends and more of our friends become patients. I have learned to welcome this as a part of my job and understand the careful nuance these relationships demand. I also know that much of what I am taught and much of what I teach will be proven wrong.

Lesson Number 3: Keep a sunshine folder.

At the beginning of my career, my section chief suggested I keep a sunshine folder, a folder in which to stash thank you notes from patients, commendations from your chairman, and other small accolades. As a cynical New Yorker, I scoffed at this idea. I remember finding the name “sunshine folder” repugnant. Nevertheless, on a day of weakness, I started one. EJ’s drawing could be in my sunshine folder if it was smaller and didn’t hang on my wall.

Why do you need a sunshine folder? Because medicine is hard. You will work harder than you ever have, and the stakes are impossibly high. Things occasionally go badly. There are bad outcomes when you do everything right — and, even worse, when you don’t. One of the things that makes the practice of medicine wonderful is that we can never become overconfident. Whenever I feel like I am really mastering the art and the science of medicine, I am sure to be reminded of how endlessly complex it is to care for people. To paraphrase William Osler, there may be a finite number of diseases, but there are an infinite number of ways they present and an infinite number of ways that we, as humans, react to them. The sunshine folder is there to brighten your spirits on the difficult days that lie ahead.

Lesson Number 4: Know your stuff.

On that November day when EJ called me, critically ill, he needed a skilled physician who knew exactly how to care for him. He did not care that I kept a sunshine folder, or doubted my teachers, or recognized that our greatest impacts are often unintentional.

Your mission is to learn as much as you possibly can for the good of your future patients. You are not working for grades, or to pass a course, or for some academic honor. If you ever say to yourself:

“I can stop studying, I know enough to pass;” or

“Well, if I fail this exam they’ll let me retake it;” or

“You know what they say, P = MD;”^[6]

stop and remind yourself of why you are studying. Yes, this is going to be hard, but it is what you signed up for and it is the cost of the privilege of being a doctor.

But do remember, while you immerse yourself, you will be accepted into medical school not just because someone thought you are smart and can do the work. You will be accepted because of who you are. Take time to be that person. Being yourself is important to your health and to the health of your future patients. Go to the museum now and then and ponder some great or enigmatic art. Take far too much interest in your favorite sports team. Take a printing or ceramics class. Spend time on that collection that your friends make fun of.

Four pieces of advice you did not ask for. I hope they are useful. Maybe jot them down and stick them in your sunshine folder. I hope they help you and inspire you to do the best you can for your future patients, and I hope you will not, someday, decide that my advice was wrong.

An earlier version of this essay was published here.

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[1] Either one. Just do something worthwhile. You can spin almost anything to look good in your application. That includes, “I needed money so I took the highest paying job I could find.”

[2] They might frown a little but if you present a good reason, you’ll be fine. A good reason is that I needed space in my schedule to take a course with amazing Professor X. A good reason is not, I thought I was more likely to get a good grade over the summer. As an aside, I met my wife taking a summer physics course to fulfill my premed requirements, so I am probably not the right person to ask.

[3] Whatever you love and can throw yourself into for 4 years.

[4] Ok, I plagiarized this one from Francis W. Peabody.

[5] I’m being historically accurate with the name. It is presently called pneumocystis Jiroveci pneumonia.

[6] That means Pass = MD, as in nobody really cares how you did medical school after you get your degree.