Opinion

PERSPECTIVE

Claudia Finkelstein, MDCM Department of Medicine, University of Washington, Seattle.

Corresponding Author: Claudia Finkelstein, MDCM, Department of Medicine, University of Washington, 325 9th Ave, PO Box 359753, Seattle, WA 98104 ([email protected]). jamainternalmedicine.com

Full Circle My daughter met her cadaver yesterday. She has begun her own journey of “things that you need to know to be a physician.” Many are taught explicitly, and so many more are implicit. I am in the high desert writing, walking, breathing, recovering from some of these same lessons. She is surprised that the woman whose body she will begin to slice open tomorrow is of my age and build. When I asked about her cadaver she said, “she’s younger than I expected, a little older than you.” She has already noticed the sharp smell of preservative and the slimy residue on the gloves—part of the price paid for this deeper knowledge. Deep although she has not even broken through the epidermis. Already the urban legends circulate among her classmates. The laboratory is so cold that she wears fleece leggings under her scrubs. In my personal dissection I have gotten to the skin layer and maybe a bit beyond. I have at least noticed my numb inability to express to her (and maybe even to myself) the depth and complexity of my emotions about her choice of livelihood as a woman in medicine. This numbness, the shutting off of emotions, has served me very well very often over the years. It has also been treacherous in times like these when I am so overwhelmed by emotion that I think I feel nothing. I have tried sending her “welcome to the profession” texts. I have attempted a heartfelt message of encouragement on a hand-painted card that ended up reading both in sentiment and in penmanship as if it were written by a fourth-grade boy. I am capable of neither emoting nor communicating at this moment. This moment that matters so much. I want to tell her that it is OK to feel nauseated, creeped out, highly privileged, and excited at once. I want to tell her that she is crossing a line that few humans cross, the line of cutting into one of our own. I want to tell her to be strong although I know that she does not need me to tell her. Crossing this Rubicon may be momentous or may slip by unnoticed—I hope that she will notice and am not sure that I ever did. I cannot even remember whether my cadaver was male or female, but I cannot forget the chemical smell high up in the back of my nose each time my hand neared my face. I prided myself on displaying no emotional or physical reaction to the dissection. Reflecting on our shared career choice, I examine how we each got there. My choice of career did not really feel like one. Certainly it was not one made with great deliberation. I spent time posing as an existentialist when not cramming for examinations as an undergraduate. I thought about engineering, not medicine, and took advanced physics. But biology came easier and was more interesting. I was sure, however, that becoming a physician was way out of my league until I met a medical student. I found out that you do not need to be a genius to

get in. It was a relief to think that I could eventually earn my keep doing something both interesting and useful with my life. I was not aware of any price beyond the stated tuition. My daughter, on the other hand, is actually an engaged learner, the kind that we all hope to teach one day. She reads the background papers and worries about conceptual integrity instead of what will be on the examination. I do not think that she believed that any career was out of her reach until partway through the nailbiting application process. It was way beyond that point in my application that I had discovered that I even had a chance. I remained distant from the process, feeling as if it was someone else’s life and future. I filled in the application and wrote what I suppose must have been a rather moving essay—if not moving, at least effective. In my role as her mother, I was careful not to be directive or to sway her toward medicine. We talked about the thrill of basic science, the poor pay of a yoga teacher, the social justice that might be achieved with an MPH degree. We talked about taking time to know her heart. Somewhat deliberately, I did not discuss medicine. After one lunch with her father the radiologist, she came home and brightly announced that she wanted to be a physician. In response to this news, I was less effusive than she may have wished or expected. I did not know what to think or how I felt. She and I share a solid stomach and tolerance for all manner of fluids, smells, and sights. We love to figure things out. We know how to hunker down and delay gratification almost indefinitely to do what needs to be done. We know how not to wear our hearts on our sleeves and get down to business. We value productive forward motion and are constantly biting off much more than we can comfortably chew. We also share a certain conviction in doing things “the right way.” Lately, I have been working to shed the concept of the one right way to do almost anything. As I have stripped this and other layers, I have become a better physician. My tears are closer to the surface, my human heart closer to experiencing a depth of feelings. I care deeply for and about my patients. As I have removed some layers, I have become a better mother (I think). I try to listen more and to say less. In both cases I begin to see the limits of my power. I smile when people ask how I feel about her choice and avoid a straight answer. “You must be so proud.” Yes, and yet there is more to it. Having finally achieved a sense of stability and joy in my professional life, how can I express my deepest feelings about her choice? I wonder whether her heart will become hardened and immune to the suffering of her patients. I wonder whether her heart will break in the face of the suffering. I wonder whether she will succeed at selective partial hardening—not the all-or-none variety: hard enough JAMA Internal Medicine May 2014 Volume 174, Number 5

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Opinion Perspective

to remain objective and effective when necessary and soft enough to cry sometimes. “I hope it does not kill her soul” rings false when coming from the mouth of one who goes around lecturing medical students about how to “Maintain Morale and Momentum in Medicine.” But deep in my Published Online: March 17, 2014. doi:10.1001/jamainternmed.2014.181.

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heart, I sincerely wish her a life of ease and joy, not one in which defensive layers are essential for survival. Layers like the fleece can be left at the door of the laboratory. The chain mail on the heart is less easily dislodged. Everything that I could not tell her in a letter I have told her here. She has assured me that she will be fine. May it be so.

Conflict of Interest Disclosures: None reported.

JAMA Internal Medicine May 2014 Volume 174, Number 5

Copyright 2014 American Medical Association. All rights reserved.

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