Your essay is a beautiful example of successful adaptation to challenging events Harrison! Rather than making endless "upward comparisons" (We fell so far short of our lofty goals) and feeling ashamed and depressed, you and your wife pivoted to "downward comparisons" (Some couples didn't match together or at all) and appreciating the value and opportunities of what you got. Your good example is one we can all learn from. Thanks for writing about it so well! 👏
Thankyou for your thoughtful reflection. I have one quibble... With the idea that if you want to be something, you are the one that makes it happen, not the institution etc... This just smells to me of an over-internalised locus of control, of the idea that you are in control of your destiny, and doesn't acknowledge the reality that we can influence but not control the others who often control our destinies... There's something in psychology called a just world theory which buys into this idea that we're all in control of our destiny; those who believe this mantra have less compassion for the underprivileged (because they are responsible for where they ended up) and less pro-social social justice policies. From the perspective of a medical student born in poverty, live with serious mental illness, first in family at university, I've been homeless as an adult, am a single parent with a child with a disability... I'm grateful I've got where I've got, but I could so easily not have, and if life got on top of me it wouldn't be because I had failed to make it happen, but because the combination of circumstances overwhelmed my coping strategies (which are pretty strong!). Being able to make your future happen usually requires wealth, health, smarts, personability... and luck.
Hey Heather, thanks so much for this comment and perspective. We wouldn't be on Sensible Medicine if we didn't enjoy the "quibbles" :)
This is something I have spent a long time reflecting on. Having been born into generational wealth, white, male, I naturally inherited a lot of privilege that makes my journey look much different than someone in your shoes. You can imagine I've been around a lot of people who consciously or subconsciously subscribe to the internal locus of control and just world theory.
It pains me to think that because of this, I may have less compassion for the underprivileged. I think it takes a lot of intentional reflection and work for someone born in my shoes to build a mindset and approach that I hope conveys compassion to those less fortunate. This idea is still rooted in that I have control over how I can treat other people, how I can better myself despite the external factors, how I can specifically contribute to society in a way that betters life fort those less fortunate. In that way, I am still relying predominately on an internal locus of control while not attributing others' places to a personal failure on their part by default.
In my mind, your challenge is going to be taking your personal experience of the external locus of control and conveying that experience to those coming from places of privilege so that they can continue to broaden their perspective, as you have done here. You've probably already experienced how difficult this can be. And above all, you should remember that despite all of the hardships you have had, you overcame them to be what you are today. Be sure to give yourself credit!
Things have changed quite a bit from when I was applying for fellowships. We did not match 30 years or so ago. We interviewed and got offers. So much easier!
I think the best approach is to consider who you want to be when you are done. If you want to be an academic researcher, climbing the faculty ladder, then you need to pursue those fellowships. However, the vast majority of us end up practicing at community hospitals, taking care of whatever walks in the door and not looking for the rare case that meets our narrowly specialized niche. I knew that I wanted to stay in the community where I grew up and trained from college through residency. There was one fellowship in my specialty, and that was the only one I looked for and had an offer from. I don't even practice that specialty any more, as I moved into more administrative medicine over time. That was certainly something I never even considered, but it has turned out to be the very best choice for me.
As a female physician who wanted to have time with her family, I found a great fit that allowed me to travel to competitions with my daughters and to be there for them when they needed me most. Now that they are grown, I find my relationship with them to be more rewarding than any academic achievements or titles. And I still love my job, even though it was not what I thought I wanted when I started the process!
What a blessing that you were given a wife and child when you were! Nothing puts all other things in perspective quite as well as the responsibilities (and joys) of having a family!
Thanks for this piece. I share a similar sentiment with Grant Mowry’s comment in addition to the sentiment of our self worth in medicine.
I’m going into my third year of medical and in my first year my daughter was born. Before my daughter was born and thereafter have felt like two different versions of my academic self. Near perfect scores were replaced with class average scores. Extracurricular involvement was replaced with morning walks in the neighborhood and playing with my daughter in the evening. Surprisingly, I don't feel any less accomplished in my studies now than I did before. I may have been doing “better” academically before but growing a family in medical school is the best thing that could have happened to me as I’ve realized what’s important and what is less so. IT IS important to study however from my experience, spending the extra hours to learn a few more factoids for a better score is not worth it. Most of us in medicine tie our self worth to our academic success but life is so much more than that.
Thank you for this piece! Incredibly uplifting! I’m reminded of Ecclesiastes 7:14: “For in the day of prosperity be happy, but in the day of adversity consider-God has made the one as well as the other…”. I believe nothing is coincidence, and everything has a purpose…including (and especially) where we match. God has a purpose in it…even if we can’t figure it out.
I agree with the general sentiment that you can still make a great career and life even if you don't end up where you think you wanted to go. However, I think the article is presenting a dichotomy between "academics" (picture snoody bearded fellow smoking his pipe in the ivory tower) vs medicine (compassionate, really much better people than those scientists). But I just don't agree with this framing at all. I was speaking to an academic hospitalist last night and he said that his research does so much to connect him to the patients and stay curious and learning about how to improve their treatments. Also, even if research did not help in the regard, I think it is insulting to science to say, "Having passionate and caring people working alongside us in those moments is infinitely more valuable than the research output of the adjacent basic science labs." Medicine should not be venerated as this thing far beyond science. It rests on the foundation of science. No matter how compassionate the witch doctor is in some village 1000 years ago, he is probably doing more harm than good. The basic science lab next door may in fact be discovering things that lead to cures or much better treatments for diseases, so it is not "infinitely more valuable". I hope you can see that research, at least in its true form (which not many med students have experienced), can have huge impacts especially in medicine.
Thanks for this comment Grant. As I re-read this today, I was hoping someone would come to the defense of the "academics". I completely agree with your point that research does bring incredible humanistic value to society that stretches to personal encounters, as you mentioned your friend saying how much more connected he feels to patients through his research (I like to imagine for instance, you were directly involved in basic science research that allowed for development of new pharmacotherapies for your patients with a rare disease that now has radically changed their lives for the better - think Trikafta for patients with cystic fibrosis). And of course our ability to heal has been greatly amplified by the advances of science.
I would add a few nuances to two aspects. First is related to some key words in your last sentence - research "in its true form (which not many med students have experienced)". I think the large majority of research output that we are ranked on (and therefore encouraged to participate in) as medical trainees is NOT research in its true form, and in some ways may actually be harmful for medicine. Vinay Prasad and the rest of Sensible Medicine crew have discussed this point before so I won't belabor it here.
Second is the notion that medicine "should not be venerated as a thing far beyond science" and that "no matter how compassionate the witch doctor was in some village 1000 years ago, he was probably doing more harm than good". I do believe that caring for a patient extends beyond scientifically finding the diagnosis and prescribing the proper treatment - robot/AI can do this. The harm done by the witch doctor you are referring to would have been prescribing harmful remedies for pathologies he/she did not understand. And yet, people look for more from their doctors: listening with intention, bearing witness to their suffering and their story, conveying a feeling that you truly care about them and what they are going through.
I spent a good amount of time learning about "alternative medicine" in my undergrad days and trying to hone in on its appeal. Why do people continue to seek out "alternative" medicine even if we know science supports one practice over the other? I believe a large part of it is that our current medical training, while rightfully celebrating the great advances of our field from science, often leaves out this emphasis on care that, as the famous Dr. Peabody quote goes, is "the secret in the care of the patient". Those who have authentically contributed to the advancement of medical science and then see firsthand the benefits for patients they care for can then experience a level of compassion and understanding alongside their patients that is unrivaled and I think that is rooted in this same idea. In that way, I believe medicine and healing is rooted in humanism more at its core than science.
Would you like to hear from someone with no medical training who, for the last several years, has been trying to stay as far away from conventional medicine as possible? Most people do not need what our medical system has to offer: scheduled office visits, monitoring and tests, pharmaceutical drugs, joint replacements, immunizations, management of chronic conditions, and the like. “Prevention is worth a pound of cure,” but prevention isn’t what we seem to get when we place ourselves into the role of the “patient.” You wondered why “alternative medicine” has “appeal.” The answer is easy; it is to have more autonomy and to realize that most medical conditions can be managed without the assistance of an MD. I certainly acknowledge that sometimes people need medical intervention, especially in the case of falls and accidents. But, as I look back over more than eighty years, I can only think of one instance in my life where a doctor’s help was probably necessary. I think we are taught to rely on doctors too much instead of managing our own health. Arguing over what is more important, academics and research vs direct care is, to me, insignificant compared to considering which is more important to the health and well being of most individuals in general: relying on a person with MD after their name, or taking some responsibility for one’s own health. ( I realize I’ve left the main discussion. My points are only loosely connected.)
Hey Lindy, thanks for the perspective from outside our medical training echo chamber. I completely agree that our current mainstream medical system is rooted in reactionary thinking (which makes sense historically, when you think about the level of disease and illness we were dealing with on a day to day basis, there was not much time to think about prevention - your day was filled with doing things to try and save critically ill patients or relieving suffering at the end of life). It is now the privilege of modernity (thanks in large part to the advances of science and public health) that prevention has become our next great challenge, and as you alluded to, arguably the most important of all.
I absolutely agree with your statement that the health and well being of most individuals in general is much more important than our squabbles over the best ways to find personal fulfillment with our careers in medicine. I would argue that you have been fortunate to not have needed much of conventional medicine, which extends beyond falls and accidents to rarer diseases and severe but potentially reversible conditions that require frequent healthcare utilization. Many people do not get that choice to turn away from conventional medicine without great personal risk.
I think your final point of trying to refocus towards people taking more responsibility for their own health is crucial in the prevention endeavor. We are only now trying to improve education in medical school on things like nutrition and coaching on how to build healthier habits, to name a few.
To circle this back to our above discussion, I think if our doctors were more in tune with connecting with the patient and able to build trust in this way, you wouldn't feel that "most people do not want what we have to offer: scheduled office visits etc" Part of why I wrote this piece was to reflect on how, at almost every level, our medical education system (for doctors specifically) emphasizes achievements in areas that often (but not always, as we learned best with Grant's comment) take us away from those skills. The result of that is then felt by patients like yourself, who then stray away from our clinics and towards unconventional things, which sometimes have much to offer as you know, but can also be dangerous.
I apologize for submitting a comment that was obviously off topic. I almost deleted it and should have. You were very kind to respond as you did. I feel compelled to mention that I have seen, in depth, the other side of the “medical” coin. My husband’s doctor referred to him fondly as his most compliant patient, and that he was. I am surprised I didn’t flee from our medical system when he died ten years ago. It was the fiasco of COVID that finally sent me running. As you stated, I am taking a “great personal risk,” and it “can be dangerous.” Those thoughts are worrisome to me, but I think the enormous regret I still have for not being the advocate for my dear husband that I should have been is manifesting itself in this way.
You touched on one of the hardest aspects of medicine the further along you get, that time is limited. Especially as your family grows, you’re going to continually be challenged with the balance between becoming the type of doctor you aspire to be and a person who doesn’t neglect the people most immediate to them. It’s challenging because as an achiever, there’s always more you can be “doing” (reading, research, studying, writing). It takes humility and perspective to recognize your limitations and obligations and set your priorities accordingly. Sometimes that can mean a loss of perceived “prestige.” I promise you if you do a good job taking care of people and maintain that sense of humility, grateful patients couldn’t care less about the institution on your diploma.
NEJM perspectives submission.
Your essay is a beautiful example of successful adaptation to challenging events Harrison! Rather than making endless "upward comparisons" (We fell so far short of our lofty goals) and feeling ashamed and depressed, you and your wife pivoted to "downward comparisons" (Some couples didn't match together or at all) and appreciating the value and opportunities of what you got. Your good example is one we can all learn from. Thanks for writing about it so well! 👏
Thankyou for your thoughtful reflection. I have one quibble... With the idea that if you want to be something, you are the one that makes it happen, not the institution etc... This just smells to me of an over-internalised locus of control, of the idea that you are in control of your destiny, and doesn't acknowledge the reality that we can influence but not control the others who often control our destinies... There's something in psychology called a just world theory which buys into this idea that we're all in control of our destiny; those who believe this mantra have less compassion for the underprivileged (because they are responsible for where they ended up) and less pro-social social justice policies. From the perspective of a medical student born in poverty, live with serious mental illness, first in family at university, I've been homeless as an adult, am a single parent with a child with a disability... I'm grateful I've got where I've got, but I could so easily not have, and if life got on top of me it wouldn't be because I had failed to make it happen, but because the combination of circumstances overwhelmed my coping strategies (which are pretty strong!). Being able to make your future happen usually requires wealth, health, smarts, personability... and luck.
Hey Heather, thanks so much for this comment and perspective. We wouldn't be on Sensible Medicine if we didn't enjoy the "quibbles" :)
This is something I have spent a long time reflecting on. Having been born into generational wealth, white, male, I naturally inherited a lot of privilege that makes my journey look much different than someone in your shoes. You can imagine I've been around a lot of people who consciously or subconsciously subscribe to the internal locus of control and just world theory.
It pains me to think that because of this, I may have less compassion for the underprivileged. I think it takes a lot of intentional reflection and work for someone born in my shoes to build a mindset and approach that I hope conveys compassion to those less fortunate. This idea is still rooted in that I have control over how I can treat other people, how I can better myself despite the external factors, how I can specifically contribute to society in a way that betters life fort those less fortunate. In that way, I am still relying predominately on an internal locus of control while not attributing others' places to a personal failure on their part by default.
In my mind, your challenge is going to be taking your personal experience of the external locus of control and conveying that experience to those coming from places of privilege so that they can continue to broaden their perspective, as you have done here. You've probably already experienced how difficult this can be. And above all, you should remember that despite all of the hardships you have had, you overcame them to be what you are today. Be sure to give yourself credit!
Things have changed quite a bit from when I was applying for fellowships. We did not match 30 years or so ago. We interviewed and got offers. So much easier!
I think the best approach is to consider who you want to be when you are done. If you want to be an academic researcher, climbing the faculty ladder, then you need to pursue those fellowships. However, the vast majority of us end up practicing at community hospitals, taking care of whatever walks in the door and not looking for the rare case that meets our narrowly specialized niche. I knew that I wanted to stay in the community where I grew up and trained from college through residency. There was one fellowship in my specialty, and that was the only one I looked for and had an offer from. I don't even practice that specialty any more, as I moved into more administrative medicine over time. That was certainly something I never even considered, but it has turned out to be the very best choice for me.
As a female physician who wanted to have time with her family, I found a great fit that allowed me to travel to competitions with my daughters and to be there for them when they needed me most. Now that they are grown, I find my relationship with them to be more rewarding than any academic achievements or titles. And I still love my job, even though it was not what I thought I wanted when I started the process!
What a blessing that you were given a wife and child when you were! Nothing puts all other things in perspective quite as well as the responsibilities (and joys) of having a family!
Thanks for this piece. I share a similar sentiment with Grant Mowry’s comment in addition to the sentiment of our self worth in medicine.
I’m going into my third year of medical and in my first year my daughter was born. Before my daughter was born and thereafter have felt like two different versions of my academic self. Near perfect scores were replaced with class average scores. Extracurricular involvement was replaced with morning walks in the neighborhood and playing with my daughter in the evening. Surprisingly, I don't feel any less accomplished in my studies now than I did before. I may have been doing “better” academically before but growing a family in medical school is the best thing that could have happened to me as I’ve realized what’s important and what is less so. IT IS important to study however from my experience, spending the extra hours to learn a few more factoids for a better score is not worth it. Most of us in medicine tie our self worth to our academic success but life is so much more than that.
Thank you for this piece! Incredibly uplifting! I’m reminded of Ecclesiastes 7:14: “For in the day of prosperity be happy, but in the day of adversity consider-God has made the one as well as the other…”. I believe nothing is coincidence, and everything has a purpose…including (and especially) where we match. God has a purpose in it…even if we can’t figure it out.
Well said.
I agree with the general sentiment that you can still make a great career and life even if you don't end up where you think you wanted to go. However, I think the article is presenting a dichotomy between "academics" (picture snoody bearded fellow smoking his pipe in the ivory tower) vs medicine (compassionate, really much better people than those scientists). But I just don't agree with this framing at all. I was speaking to an academic hospitalist last night and he said that his research does so much to connect him to the patients and stay curious and learning about how to improve their treatments. Also, even if research did not help in the regard, I think it is insulting to science to say, "Having passionate and caring people working alongside us in those moments is infinitely more valuable than the research output of the adjacent basic science labs." Medicine should not be venerated as this thing far beyond science. It rests on the foundation of science. No matter how compassionate the witch doctor is in some village 1000 years ago, he is probably doing more harm than good. The basic science lab next door may in fact be discovering things that lead to cures or much better treatments for diseases, so it is not "infinitely more valuable". I hope you can see that research, at least in its true form (which not many med students have experienced), can have huge impacts especially in medicine.
Thanks for this comment Grant. As I re-read this today, I was hoping someone would come to the defense of the "academics". I completely agree with your point that research does bring incredible humanistic value to society that stretches to personal encounters, as you mentioned your friend saying how much more connected he feels to patients through his research (I like to imagine for instance, you were directly involved in basic science research that allowed for development of new pharmacotherapies for your patients with a rare disease that now has radically changed their lives for the better - think Trikafta for patients with cystic fibrosis). And of course our ability to heal has been greatly amplified by the advances of science.
I would add a few nuances to two aspects. First is related to some key words in your last sentence - research "in its true form (which not many med students have experienced)". I think the large majority of research output that we are ranked on (and therefore encouraged to participate in) as medical trainees is NOT research in its true form, and in some ways may actually be harmful for medicine. Vinay Prasad and the rest of Sensible Medicine crew have discussed this point before so I won't belabor it here.
Second is the notion that medicine "should not be venerated as a thing far beyond science" and that "no matter how compassionate the witch doctor was in some village 1000 years ago, he was probably doing more harm than good". I do believe that caring for a patient extends beyond scientifically finding the diagnosis and prescribing the proper treatment - robot/AI can do this. The harm done by the witch doctor you are referring to would have been prescribing harmful remedies for pathologies he/she did not understand. And yet, people look for more from their doctors: listening with intention, bearing witness to their suffering and their story, conveying a feeling that you truly care about them and what they are going through.
I spent a good amount of time learning about "alternative medicine" in my undergrad days and trying to hone in on its appeal. Why do people continue to seek out "alternative" medicine even if we know science supports one practice over the other? I believe a large part of it is that our current medical training, while rightfully celebrating the great advances of our field from science, often leaves out this emphasis on care that, as the famous Dr. Peabody quote goes, is "the secret in the care of the patient". Those who have authentically contributed to the advancement of medical science and then see firsthand the benefits for patients they care for can then experience a level of compassion and understanding alongside their patients that is unrivaled and I think that is rooted in this same idea. In that way, I believe medicine and healing is rooted in humanism more at its core than science.
Would you like to hear from someone with no medical training who, for the last several years, has been trying to stay as far away from conventional medicine as possible? Most people do not need what our medical system has to offer: scheduled office visits, monitoring and tests, pharmaceutical drugs, joint replacements, immunizations, management of chronic conditions, and the like. “Prevention is worth a pound of cure,” but prevention isn’t what we seem to get when we place ourselves into the role of the “patient.” You wondered why “alternative medicine” has “appeal.” The answer is easy; it is to have more autonomy and to realize that most medical conditions can be managed without the assistance of an MD. I certainly acknowledge that sometimes people need medical intervention, especially in the case of falls and accidents. But, as I look back over more than eighty years, I can only think of one instance in my life where a doctor’s help was probably necessary. I think we are taught to rely on doctors too much instead of managing our own health. Arguing over what is more important, academics and research vs direct care is, to me, insignificant compared to considering which is more important to the health and well being of most individuals in general: relying on a person with MD after their name, or taking some responsibility for one’s own health. ( I realize I’ve left the main discussion. My points are only loosely connected.)
Hey Lindy, thanks for the perspective from outside our medical training echo chamber. I completely agree that our current mainstream medical system is rooted in reactionary thinking (which makes sense historically, when you think about the level of disease and illness we were dealing with on a day to day basis, there was not much time to think about prevention - your day was filled with doing things to try and save critically ill patients or relieving suffering at the end of life). It is now the privilege of modernity (thanks in large part to the advances of science and public health) that prevention has become our next great challenge, and as you alluded to, arguably the most important of all.
I absolutely agree with your statement that the health and well being of most individuals in general is much more important than our squabbles over the best ways to find personal fulfillment with our careers in medicine. I would argue that you have been fortunate to not have needed much of conventional medicine, which extends beyond falls and accidents to rarer diseases and severe but potentially reversible conditions that require frequent healthcare utilization. Many people do not get that choice to turn away from conventional medicine without great personal risk.
I think your final point of trying to refocus towards people taking more responsibility for their own health is crucial in the prevention endeavor. We are only now trying to improve education in medical school on things like nutrition and coaching on how to build healthier habits, to name a few.
To circle this back to our above discussion, I think if our doctors were more in tune with connecting with the patient and able to build trust in this way, you wouldn't feel that "most people do not want what we have to offer: scheduled office visits etc" Part of why I wrote this piece was to reflect on how, at almost every level, our medical education system (for doctors specifically) emphasizes achievements in areas that often (but not always, as we learned best with Grant's comment) take us away from those skills. The result of that is then felt by patients like yourself, who then stray away from our clinics and towards unconventional things, which sometimes have much to offer as you know, but can also be dangerous.
I apologize for submitting a comment that was obviously off topic. I almost deleted it and should have. You were very kind to respond as you did. I feel compelled to mention that I have seen, in depth, the other side of the “medical” coin. My husband’s doctor referred to him fondly as his most compliant patient, and that he was. I am surprised I didn’t flee from our medical system when he died ten years ago. It was the fiasco of COVID that finally sent me running. As you stated, I am taking a “great personal risk,” and it “can be dangerous.” Those thoughts are worrisome to me, but I think the enormous regret I still have for not being the advocate for my dear husband that I should have been is manifesting itself in this way.
You touched on one of the hardest aspects of medicine the further along you get, that time is limited. Especially as your family grows, you’re going to continually be challenged with the balance between becoming the type of doctor you aspire to be and a person who doesn’t neglect the people most immediate to them. It’s challenging because as an achiever, there’s always more you can be “doing” (reading, research, studying, writing). It takes humility and perspective to recognize your limitations and obligations and set your priorities accordingly. Sometimes that can mean a loss of perceived “prestige.” I promise you if you do a good job taking care of people and maintain that sense of humility, grateful patients couldn’t care less about the institution on your diploma.