Forward.

A little over 6 years ago, I was wandering through the Chicken Street bazaar in Kabul with some friends.  We were in a carpet seller’s stall.  Afghan carpets are world renowned.  Think stacks upon stacks of fine works of art in a 10 x 10 room with a small door open to the dusty street, with a view of hanging goat carcasses, babbling chickens and artisans of all kinds.  I sat on a stool sipping chai, watching one of my gregarious friends chat with the seller.    

Photo by Trang Nguyen on Unsplash

Photo by Trang Nguyen on Unsplash

Sitting there, looking at carpets I could not afford, I got an email on my Blackberry from the Northern Ontario School of Medicine.  They told me that I did not get into medical school.  Again.  It was my second rejection from that school, after interviewing once in 2007 and again in 2011.  I had flown to Thunder Bay from Kabul three months earlier to interview.  I was pleased with my work.  They were not.

Two years ago, I finished medical school.  Three days ago, I finished my residency in family medicine and I am now licensed to practice independently.  I start my clinic in two days and ER work in two weeks.

After my second rejection, I doubled down.  I left my work in Afghanistan so I could take more courses so I could rewrite the MCAT so I could apply to more schools.  At the same time, I applied to schools in New Zealand and the Caribbean.  I could afford none of this.  I didn’t know if it would work.  I was really scared but bullish in the way one can be in their mid-20s.  I got into the Michael G. DeGroote School of Medicine in May 2012.  I am not exactly sure how.  I feel lucky.  It’s probably too late for them to change their minds. 

But this is the job for me.  This one.  Being a doctor.  And I knew that.  I have some really straight-up basic reasons: to help people, to learn forever, science is nifty and Canada’s system almost works.  And I also have a reason that is totally mysterious to me.  It is the feeling of alignment and order, and internal symmetry, that comes about when I am at the work of helping people with my hands.  It is a whole-hearted soul-level knowing that I am in the right place at the right time.

But there was a lot, more than I could have imagined, that I didn’t know about what it means to be a doctor.  I had no idea how it would feel to be so close to peoples’ most intimate problems.  How it would feel to deliver a blue, limp baby.  And then to hear that baby cry!  How it would feel to push on the chest of a dead person and have them come back to life.  Or not.  How it would feel to see a young person be utterly clueless about what they are going to do to survive their most insecure years.  How it would feel to see people smoke or drink themselves to death without realizing that they won’t get another shot at the wagon.  How it would feel to watch smart people lose their minds.  How it would feel to watch marriages dissolve.  How it would feel to care so goddamn much about so many people. 

I never could have known.  And all that comes with this, the most penetrating thought of all thoughts: What if I am not good enough?

What if I can’t do this?  What if I can’t serve fully enough?  What if, in serving in the fullest way I can, I myself fall apart?  Am I strong enough to care this much?  Will I ask for help when I need it?  Will it be there?  I hope so.

I am, at the very least, an enthusiastic, fully-credentialed imposter.   Forward is my most familiar direction.  I can keep doing that.  I can keep making the next right choice.  And I believe this is normal for my stage and training.

The medical training process is full of quagmires.  It demands that learners be flexible, assertive, memory-ready, fast and observant.  At the same time, if you bend over backwards to meet the needs of the situation, you risk being seen as a pushover.  Too assertive and you’re acting irresponsibly.  Not assertive enough and you “think like a nurse” – a thing I was actually told by my attending in 2015.  Too fast and you’re not compassionate enough.  Too slow and you’re not keeping up.  Too observant and you actually see the health care system for what it is: cancer-obsessed, moralistic and dedicated to managing disease until its dying breath, without real dollars for preventing any of it.

As a doctor, I am beholden to the individual patient before me.  And their disease(s) is(are) actually two things:  The disease itself – symptoms and prognosis.  And how the patient thinks about the disease – this is called the illness experience by the College of Family Physicians of Canada.  This is where we get at pain, sorrow, anxiety, disability.  And hope.  Stubborn, belligerent people live for a long time.   I think this is because they have irrational hope.  That’s a good thing.

In a single payer system, like the one we have in Canada, I am also beholden to the society of patients and providers to which I belong.  A dollar I order spent here is a dollar not spent there.  If I know a test I order will not change anything about my management, I should not order it.  But everyone comes to their doctor with legendary stories about young people with tumours that weren’t caught because a test wasn’t ordered.  Cancer is everyone’s scariest endgame.  And their doctor is clearly an idiot for not ordering that test, even though the government told me it was unnecessary.  Tell that to a dying person.  You will feel like a fraud nine times out of ten.

Western medicine is about the management of disease.  I have learned how to tinker with pills to generate better metrics from a human body.  I have learned how make a heart start again using electricity and pressure.  I have learned many facts.  I can identify lots of rashes and spots.  Many of the things I have learned will withstand the test of time – especially the first principles of physiology – but many won’t.  I will have to file and remember new ideas so that I can call upon them at the right time.  All of this is important, and expected, by patients and colleagues.  I will do my very, very best.

Photo by Matt Briney on Unsplash

Photo by Matt Briney on Unsplash

But wellness? No. That’s not our jam in the West. 

At the end of a 15 minute visit, I have a crunched moment or so to talk about movement, nutrition, spirituality, community, identity.  Even when the patient comes to see me to talk about depression, it can be hard to cover all of the ‘wellness’ ground I know about because of my other lives and also determine suicide risk, discuss the benefits and harms of anti-depressants, time off work and impact on the children in the home.  I want to talk about sleep, purpose, childhood wounds, parenting, money and all of it.  All of it matters to a person suffering existentially like this.  And I don’t have the time for it.

The work ahead of me is making time for wellness.  In and around disease management, there must be time to go deeper and figure out how my patients can lift themselves up.  This is my greatest defense against burnout.  This is my next right thing.