Twenty-five years ago, just months before I was to enter medical school, I served as a translator for a surgical mission. A team led by plastic and general surgeons from the University of Minnesota descended on a small concrete-block dispensary in the highlands of Guatemala, turning it, for one week, into a makeshift surgical hospital.
Guatemalan colleagues had already screened and selected a full slate of patients — enough to keep two operating rooms going twelve hours a day for six days. And then Sebastian arrived.
Sebastian was 28 years old. He had been born with a deeply cleft lip and palate. And because he was born poor in Guatemala, his craniofacial abnormality had never been corrected. It was difficult to look at Sebastian. His upper teeth were twisted into the cleft, tenting up his nostrils. When he ate, food sputtered into his nose and sinuses.
The surgical outreach was to run from Monday to Saturday, and somehow, the Sunday before it began, Sebastian found out about it. He dropped everything to travel several hours by foot and on buses until he arrived at the clinic late Monday afternoon. There he learned that he was too late. He would have to wait until a future year, because the schedule was already full, indeed too full, of patients.
But Sebastian had already waited too long to give up now. He refused to leave. Instead he sat all day just outside the entrance to the infirmary. He slept all night on its stone steps. Every time the surgeons and anesthesiologists passed by, he would plead: Please help me. I’ll do anything. Please.
This went on day after day, until the morning of the final day, when the head surgeon suddenly announced to the team, “If we can finish the scheduled cases by 5 p.m., I am going to add this Sebastian guy on.” They didn’t finish the scheduled cases until 7 p.m., but by then no one was willing to turn Sebastian away. He was already on a gurney being prepped by an anesthesiologist, his eyes flashing with the eagerness I think. The surgeon explained that, in accordance with standard protocol they would repair the cleft palate now, and Sebastian would need to have the lip repaired in the future after the palate had healed. Sebastian shook his head wildly and begged, “Please do both operations. I don’t care about the risks.” Perhaps the surgeon was too tired to argue at that point, but he conceded. Okay. We’ll try to do both.
For the next four hours I watched a small miracle unfold. As most of the team members were breaking down equipment and packing up for the flight back to the United States, all three plastic surgeons crowded into Sebastian’s O.R., working in an almost mystical harmony to reconstruct the patient’s palate and lip as quickly and effectively as possible. And when the surgeons finished, the result was magnificent — of the 10 or 12 cleft repairs done that week, none resulted in a more anatomically clean and precise appearance. Sebastian looked like a man who had been hit by a broken bottle, but you could tell he would heal up fine. His life, quite literally, would be transformed.
As you can imagine, the moment was thrilling. I had seen doctors at work, and I was captivated.
Vocation and “Pretending”
What does it mean to have a calling to medicine? And how does one actually become the physician one feels called to be? Every summer, at medical schools around the country, young men and women go through “White Coat” ceremonies to mark the beginning of the long adventure that is medical training. In donning their white coats—the traditional garb of physicians—these students are, of course, only pretending. They are no more physicians than they were the day before.
In a critical sense, however, this pretending is intrinsic to being a physician, and, indeed, to being human. Jonathan Lear, a philosopher at the University of Chicago, notes that to be human is to pretend, because to be human is to put ourselves forward in our various social roles and practical identities. We put ourselves forward as worshipers and as skeptics, as fathers and mothers, as friends and colleagues. And we put ourselves forward as physicians. That is what the white coat symbolizes: a new way of putting oneself forward in the world.
And in putting ourselves forward, we know that our pretending may fall short of what it proposes to be. I know down deep that in putting myself forward as a physician, I may fall short of being a physician.
Before completing their training, medical students do not yet know how to put themselves forward as physicians. They are taught by senior physicians in prescribed, ritualistic, time-tested ways. They study biochemistry, pathology, physiology, embryology, immunology — indeed all of the “-ologies” that constitute medical science, and they learn to put themselves forward as people who make use of all of this medical science to preserve and restore health.
They learn also that medicine is much more than scientific knowledge. It is a practice of attending to those who are sick. So an important part of medical education is learning to put oneself forward as a clinician, as one who attend to patients. This means knowing how to introduce oneself to patients, to establish rapport, to ask questions, to listen, to examine, to counsel, and to cultivate doctor–patient relationships that facilitate rather than frustrate healing.
Gradually, the way medical students put themselves forward as physicians comes to seem less like pretending. The strange new vocabulary — several thousand new words in the first two years — becomes the grammar of a fluent second language. The practices they initially imitate awkwardly become as familiar as combing their hair or tying their shoes. The norms and commitments of their teachers become their own. Their white coats look less crisp and bright but feel more comfortable; and, eventually, the coats start to fit. The students have become physicians.
Yet, even then — even when and they receive the official title of doctor, even five or ten or twenty years into their careers when doctoring is as familiar as their own voice, physicians will still sense that in putting themselves forward, they often fall far short of being the physicians they have been trying for years to become.
That is the nature of things, not only because living up to the best standards of medicine is incredibly difficult (it is), but also because at times the standards themselves fall far short of capturing what it means to be a physician. In other words, a physician who is characterized by patient-centered communication, hitting quality-care benchmarks, medical professionalism, and any number of other socially prescribed standards may still be arrested by the sense that all of this falls short of what it would mean to become the physician he or she is called to be.
By falling short I don’t mean failing. It is possible to be a terrific medical student while recognizing that you are never fully the student you should be. And it is possible to be a terrific physician while never becoming fully the physician you aspire to be. Thankfully, if we recognize that our grasp on what it means to be a physician will always be partial, incomplete, we can let go both of the anxiety that we do not measure up and of the presumption that we do.
Becoming a Physician
My hope for each young doctor is that they will come to experience medicine as a vocation. Vocation is originally a theological concept — the idea of a work or occupation within a faithful community, to which one is summoned or called by God. Many come to medicine with just such a sense of calling, and to understand and work out how medicine fits within a good and faithful life, physicians will need to probe the depths of their moral traditions, whether religious or secular.
Medicine as vocation differs from medicine as merely a job. Insofar as one practices medicine as a vocation, one does so for the rewards internal to the practice, e.g. the rewards of attending to those who are sick, of bringing a measure of health, of comforting the dying, and so on. In contrast, insofar as one practices medicine as merely a job one does so for external rewards—for money, or prestige, or security, to please one’s parents, or just to get by. To practice medicine in this latter way is akin to play-acting; it is to act out a role but keep that role at a distance. It is a form of detachment from the call that medicine makes on one’s life.
To practice medicine as a vocation is very different; it means putting oneself forward not merely as a physician but in order to become a physician. Becoming a physician is not easy. It is hard to get the hang of it. But becoming a physician is a high calling, worthy of a lifetime of effort.
- How can we invite medical trainees to explore the meaning of the work to which they believe they are called?
- How does one discern a vocation to medicine or another profession?
- Are there ways in which we all, whatever our careers or vocations, are “pretending” to be what we are striving to be?
[An earlier version of this reflection was delivered at a Pritzker School of Medicine White Coat Ceremony.]