Becoming a Physician: A 40-year Retrospective on Medical Socialization

The medical training and socialization process can be stressful and at times even traumatic. Medical students must develop ways to nurture their vitality, refine their values, be true to theirselves, and develop their capacities as healers in the face of the difficult medical socialization processes. This article outlines the challenges of medical training and socialization, and then reviews well-established principles and practices for becoming a vital, skillful, and healing physician.


Becoming a Physician: A 40-year Retrospective on Medical Socialization
Michael McGee. 1 I recently was cleaning out my files when I came across a longforgotten paper I had written in 1982, at the tender age of 24, during my fourth year of medical school.I entitled it, "Becoming a Physician."I wrote it during a time of distress and confusion as I struggled with what I experienced as harmful about the medical socialization process.
I read it to my wife, who remarked, "that sounds a lot like you!"I too felt struck by the relevance, 40 years later, of much of my thinking about the medical socialization process.While much has changed, medical socialization is largely the same 40 years after writing this paper.I'd like to share my observations, now nuanced by my 40 years of experience as a psychiatrist.I think you'll find that much of what I have to say is as relevant now as it was 40 years ago, if not more so.
As for many of us, those medical school years were trying, turbulent years filled with anxiety, confusion, self-doubt, conflict, and anger, and also with excitement, joy, and a profound sense of fulfillment.A large part of my struggle was an attempt to understand what I was going through, to know myself better, and to begin to change parts of myself that were causing me pain.And then there was a part of me that struggled to maintain true to what my gut told me was healing in the face of what seemed harmful.My suffering was focused both internally and externally.In particular, I frequently experienced anger towards "the system" for what I slowly realized were its inadequacies and its harmful effects on me and my classmates.My resistance to looking inward intensified my anger.Still, the system made us suffer unnecessarily at times, didn't give us support when we did suffer, and taught us a technologically-oriented brand of medicine which is sometimes inhumane and incomplete.And this was at Stanford, supposedly once of the best medical schools in the country.Then, as now, modern medicine is in a crisis of imbalance, in which it serves science more than humanity.I did several things to reduce my distress.I read avidly about medical training, professional socialization, and about effective healing and the inadequacies of our profession.I saw a counselor, joined a support group, took time off to pursue some of my other interests, and started keeping a journal.
Developing an understanding of my training process, and a set of personal guidelines for negotiating it, were essential for my own well-being.The following is a distillation of this understanding.
Little of what I have to say is new; I have abstracted from the many who have affected my own thinking.Most of all, I hope this will be helpful to other medical students and new doctors who struggle with the same universal stresses, conflicts, and hardships.At the least, may it stimulate thought and awareness of some issues important to our growth and health, and promote further personal exploration.
One caveat: while many of the issues discussed below persist from 40 years ago, we have also seen progress.Largely gone are the grueling 36-hour shifts and chronic sleep deprivation.More and more, medical schools recognize the importance of compassionate care, and prioritize wellness and the cultivation of interpersonal skills. 1 Educators increasingly recognize the connection between clinician vitality and clinical outcomes. 2

A Process of Change
Our metamorphosis, symbolized by our taking on the name "doctor," entails not only the addition of skills and knowledge, but an evolution of the way we see ourselves.We develop a new identity by shedding old parts of ourselves and growing new ones.We lose our prohibitions against probing naked strangers' bodies, sticking needles into people, and asking people about their sex lives, and we also learned to make life-or-death decisions.
Inevitably, change occurs with pain, for we are creatures of habit.Changing is challenging and demanding for all of us.Someone once said life is like practicing the violin in public.Practicing such a difficult art as medicine for the first time can indeed be frightening and unnerving.
Changing is easier if we know that any change, especially in our identities, inevitably stirs up an inner turmoil.This feeling is natural.If we remember that to change is to become something new and hopefully better, we have some control of how we change.With a sense of control and self-responsibility, change becomes a rewarding process of approaching the goals that contribute to the richness of our lives.

A Demanding Process
Becoming a physician requires that we confront stresses on par with those of boot camp training.Perhaps the major difference is that boot camp does not last nearly a decade.These stresses arise from dealing with illness and death and from the structure of our training.The stresses we experience are several: • The stress of high expectations: Our culture sees physicians as brighter, harder working, and more dedicated than other people.Patients expect us to provide a cure for every ill, since Modern Medicine has all the answers.Moreover, most of us adopt these demanding expectations for ourselves so that stress now comes from both without and within.Almost every psychiatrist experience this when a patient commits suicide.Many physicians find it traumatic when a patient dies of a serious illness. 3Information stress: Another stress arises from the difficulty our brains face in processing and storing the overwhelming amount of information required to be a doctor.We are overworked, and experience both emotional and physical exhaustion, as well as isolation from the world.If we are perfectionist-as most of us are-attempting to reach this impossible summit will cause us pain.With this dilemma, we face an arduous task of allocating our limited time between work and personal life as we attempt to acquire necessary knowledge.
• Stress of failure and success: And what if we don't learn enough?The threat of failure always looms large.Success is also threatening; when we succeed, we become different in the world's eyes and must take on the major responsibilities of doctoring, with all its trials and frustrations.
• Status stress: Coming from the top of our class in college and finding ourselves at the bottom of the pile in medical school.When I came to Stanford, one of my classmates was a genius who had won thousands of dollars on Jeopardy.I suddenly felt that I didn't belong.I loved histology, and studied the textbook thoroughly.I was humbled when I didn't do as well on the exam as many of my classmates.
• Existential stress: There is nothing like immersing ourselves in death, illness, and suffering to prompt us to ponder our mortality.While stressful, this is beneficial.For some, it happens while dissecting our mortality in anatomy lab.For me, the miracle of the human body manifested from the instructions of 23 pairs of molecules was a spiritual experience of awe and wonder.
• Stress of the learning process: learning clinically irrelevant material from basic scientists who have little empathy for the practices of medicine, taking and possibly failing exams, suffering the humiliation of superiors who may deride us for our ignorance, "pretending" to be doctors when we are not, probing the various orifices of people's naked bodies, and facing the pain of sickness, suffering, disability and death.My first assigned physical exam was of a woman who was dying of metastatic brain cancer.I was to go in and do a "complete" physical exam, including a rectal exam.To my enduring regret, I did as I was told, and subjected this poor, dying woman to this unnecessary exam.
The list goes on.Depending on who we are, (our attitudes, beliefs, values, and ways of coping), each one of these stresses affects us differently.Some adapt without even a flinch; Some suffer tremendous pain.Suffering manifests as anxiety, depression, strains in relationships, doubts about continuing in medicine, or even as Medical Student's disease-believing we have some disease we have recently studied.
Like change, these stresses are unavoidable.They are an inevitable part of our profession and of life.Becoming a physician is stressful for everyone; there is virtually no one who is not anxious, depressed, or who does not think about quitting medical school.We all resolve our conflicts differently, by changing whatever it is about us that causes us to suffer in response to stress.
Like changing, coping with the many stresses of our work brings rewards.With awareness and acknowledgement of these stresses, we are less confused and understand our experiences better.We have clues to what causes our pain and can make changes either in ourselves or the world to lessen our discomfort.

Satisfying Our Needs
In his book, Coping in Medical School, Virshup suggests that the primary task of medical school (and of life) is to optimally satisfy our many needs. 4We all have universal, powerful needs that, when satisfied, leave us feeling well.We classify these needs as physiological needs (for food, sleep, rest, sex, etc.) and psychological needs.Psychological needs include: 1.The need for attachment-close, supportive, relationships with other people.This can include a partner or friends with whom we share everything that is happening, and everything we are thinking, feeling, and doing.Life is a team sport; we need the support of others to survive and thrive.
2. Individualization-our own personal identity, authenticity, and independence; the synthesis of autonomy and interdependence is the greatest of all human challenges, especially when as trainees we are subject to power differentials.I once told a professor during an operation that I was uncomfortable with his homophobic remarks.It was terrifying to be true to myself, but it met my need for authenticity and to voice my distress over hateful speech.
3. Self-esteem-a feeling that we are basically good, competent people.Supervisors can threaten this need if we receive harsh criticism of our work.
4. Self-approval-acceptance by our internal critics of our thoughts, feelings and actions.We develop competence from a place of incompetence: "Every master was once a disaster."At times we experience a lack of coherence between our ideal and our actual thoughts, feelings, and actions, such as when we avoid spending time with a challenging patient.Richard Schwartz, in his book, "No Bad Parts," provides a model of health based on integration and acceptance of all of who we are. 5 Security-for example, money, a steady job and stable relationships.In our profession, this threat arises most commonly when we suffer mental or physical impairment that jeopardizes our ability to work.In many states, consumer advocates promote a punitive approach by medical boards that favor license revocation over rehabilitation.
6. Creativity and self-expression.Working 16 to 36 hour shifts up to 7 days a week can preclude the satisfaction of our need for creativity and self-expression.I felt this in medical school; I took off a year in the middle of medical school to study and play jazz piano, but had to give this up during my internship.
We can trace nearly every woe of the world back to not satisfying one or more of these needs.When our needs are unfulfilled, we feel pain--a clear message that something is wrong.With pain comes depression, anxiety, frustration, confusion, or anger.We must be able to cope with this deprivation, a skill that medical school and our careers provide us many opportunities to learn.
We cope poorly when we do not satisfy our needs--when we react to pain by becoming anxious, alienated, chronically angry, or depressed, when we deny our pain, or when we treat it ineffectively, with food, drugs, overwork, or suicide.
We cope well when we take responsibility for satisfying our needs.
To start, we must first look at ourselves squarely and honestly, so we know who we are, what our needs are, and when these needs are not being met.Accepting we have needs we would rather not have is also a must.This acceptance requires being sensitive to our feelings, listening to that "wise person" inside us who knows when things are not right and what to do.When we suffer, we can then understand the problem and work out a solution.
Coping well is difficult, especially in medicine, where the demands and stresses are great.We must endure our dependence on our profession, risk our self-esteem in our unending incompetence, face our internal critics' demands for impossible perfection, and compromise relationships and other interests to the overwhelming demands of medicine.We must even forego some of our most basic needs, such as sleep.
We must cope with the conflicts that arise by coming up with personal, creative solutions that provide us with optimal satisfaction.We should consider as many options as possible, including leaving medical school.Our solutions vary with our coping styles, as well as the relative strengths of our needs.However, we all end up making compromises and sacrifices.
We must also set limits and say "no" self-confidently to other's demands.But we must strike the balance, not our superiors.For example, I don't do well without sleep.On one of my clinical rotations, I fell in to bed, exhausted, around 2AM.My resident chewed me out the next morning for my "laziness" and "lack of dedication."I felt bad, but knew I couldn't stay up any longer and be effective.Sometimes setting limits like this will meet with stern disapproval.
If, however, our calling to become a physician is great enough, the decision to persevere brings us the greatest satisfaction, despite these hardships.

A Unique, Individual Process of Becoming
As we become doctors in medical school, we also grow and change in all aspects of our lives.We are each becoming someone who is like no other individual.Ideally, we will know our needs as we grow, and satisfy them in creative, personal ways.Rogers coins this process "becoming who we are," because in it we shed masks and games and discover our true feelings, emotions, talents, strengths, weaknesses and "hang-ups."

Self-Honesty
Being who we are is not being what our professor or mother tell us we should be, or denying feelings we would rather not have, such as anxiety on our first clerkship.It is ridding ourselves of unrealistic or inappropriate expectations of what a doctor should be and of that malignant perfectionism so common among us.
This candid self-honesty can be painful or disturbing when we discover our "undesirable" qualities.But with that pain comes self-knowledge, a reward that frees us to choose to live our lives in a way that brings us the greatest fulfillment.We can discard old expectations and a skewed self-image cast in our upbringing to adopt an image and an ideal that best fits who we are and who we wish to become.

Self-Acceptance
To be ourselves, we must accept ourselves.We must value ourselves as competent, worthwhile beings, regardless of our achievements, human flaws, and inner contradictions.If we value who we are, then we are okay, regardless of what others think.If we acknowledge our unskillful traits, we save ourselves from much grief.
Self-acceptance also strengthens our ability to accept others and forgive them for their faults; thus, we avoid an inappropriate judgmentalism that prevents us from caring.Acceptance also tempers our anger when others do not meet our expectations.With self-acceptance comes humility, a much-needed antidote to the hubris of our profession.Yet when we are arrogant or even hate our patients, our self-value remains secure because we attempt to understand what we're feeling and why rather than denying or condemning those feelings.

Being true to ourselves
Becoming who we are involves making choices based on what we, and not others, believe is best for us.Our profession places heavy demands on us to act "professionally", to neglect our wellbeing and deny our universal human needs.If we are true to ourselves, we eventually find ourselves not conforming with the world and facing, in our dependency, the criticism of our superiors and peers.With self-knowledge and acceptance, we can meet our conflicts with the world with confidence in our internal evaluation of what is best for us.We can withstand criticism without becoming hostile or defensive, and satisfy our needs assertively (respectfully, kindly, and firmly).
Usually, our respect and care results in harmonious relationships, but this is not always possible or desirable.One former mentor of mine even believed it is a step forward to have an enemy or two.
Freeing ourselves from external "shoulds," and placing more trust in our experience are essential to our well-being.
Becoming who we are is a lifelong process of self-awareness, not a discrete achievement like getting into medical school.As life is a process, so are we, and our willingness to acknowledge this frees us to change and grow as we live our lives.Self-knowledge provides a sense of direction and personal meaning to our continual self-discovery and change.Our years of medical training are then a rewarding process of becoming the physician we are, the only people we can be truly happy being.

Self-Responsibility
We all feel responsible for meeting whatever demands our profession makes of us, since we depend on it for our training, and our relationships with colleagues have such a powerful impact on our well-being.In fact, we are responsible to others for honoring our commitments, interacting with honesty, respect and care, giving both technologically and humanistically competent care.But our primary responsibility is to "be who we are", to satisfy our needs and live our lives as we see fit.If our educational needs are not being met, we should take action to satisfy them.If the "ideal doctor" others prescribe does not fit us, then we must take responsibility to craft our own ideal.We must not be afraid to be different or to disagree with those around or "above" us.Self-responsibility is an attitude of active control; we do not settle passively for what others hand us or allow ourselves to sculpt us after someone else's image.We are responsible for resisting the harmful aspects of our professional socialization.
Only we can ensure that we become who we are.Selfresponsibility requires becoming self-aware, self-accepting, and confident, not an easy accomplishment in the face of our inexperience in an intimidating profession.Not easy, but not impossible, and certainly essential to our well-being.As we "practice" medicine, we constantly judge our actions against an internal ideal-self that guides our growth.We develop this ideal-self with input from society, our teachers and our colleagues.Unfortunately, many of the ideals prevalent today, such as "the doctor is inexhaustible", "the doctor puts medicine before all else" or "the doctor is a scientist", harm us or decrease the quality of our care.We all need work that is effective and rewarding; therefore, we must have an ideal that fits who we are and optimizes our ability to heal others.

Need for Direction-An Ideal
What are the qualities of an effective healer?Many gifted writers, such as Reiser, Preston, Remen, Cousins, and Engel provide helpful answers to this question.(See suggested readings).

A Healing Relationship
A universal theme is the profound importance of the relationship between the doctor and the patient.Deckert, in his review of over fifty studies on physician qualities vs. patient outcomes, found that the most important qualities were the doctor's abilities to give nurturance, to educate patients about their diseases, and to involve patients in their care. 6Location of training and Board scores do not correlate with patient outcomes.

Strong interpersonal skills
An optimal patient outcome therefore requires that we have welldeveloped interpersonal relationship skills.We must understand human psychology, accept the patient non-judgmentally, empathize (understand what another person is experiencing), and communicate in a skillful and sensitive manner.Above all, we must be willing to establish close, personal relationships with patients, for only then can we effectively inspire, encourage, nurture, support, and instill hope.
"The essence of the practice of medicine is that it is an intensive personal matter... at first sight, this may not appear to be a very vital point, but it is, in fact the crux of the whole situation.The treatment of disease may be completely personal.The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized.For and an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients."-F.W. Peabody. 7

A Holistic, Biopsychosocialspiritual Perspective
Engel's biopsychosocial model provides an understanding of how social, cultural, familial, and psychological factors contribute to a person's illness. 8These factors are parts of an indivisible totality.We must understand patients in their entirety to most effectively help them.We must approach each patient with the attitude that this is a unique person struggling with an illness, not an interesting "case".The doctor who treats only disease avoids responsibility for the problem.He is treating himself rather than serving the patient.
A narrow biomedical perspective has the potential for great harm.
For example, we label a person with a disease process and then prolong suffering with unnecessary treatments that do not address the cause of the person's suffering.We also do harm when we are insensitive and shatter hope, withhold support, neglect feelings, or cause panic.Stress and emotions have a tremendous impact on the healing process.We are therefore incompetent if we do not address them as part of our work.
Unlike learning the differential diagnosis for abdominal pain, healing requires more than intellectual commitment.We must not only diagnose and treat, but also "assist human nature and provoke no needless upset."This requires that we relate effectively, nurture, inspire, and encourage-skills that stem not so much from what we know, but from who we are-our life philosophy and values and our relational capacities.Medicine is an art, practiced with reverence for human life.The quality of our work depends on our qualities as people: humility, dedication, wonder, understanding, respect, and care.

Care
Above all, care is the most important quality we bring to our work.Care gives us the motivation to serve despite the hardships of medicine.From care comes our ability to relate to others closely and promote healing.With care, science serves our humanity, and not vice versa.
Fletcher and other medical ethicists believe that care, (or love, in the sense of valuing others well-being as we value our own), is the ethical foundation of medicine. 9They argue that, since we are servants assisting others in their healing, our actions are ethically justified only if our motivation to arises from an altruistic concern for our patients' well-being.With this as our primary concern, we address the patient's suffering, not only their disease, and thus serve them, not ourselves.
Care is not an action, but a character trait.In his book, The Art of Loving, Fromm describes care, (a component of love) as an "inner activity" that unites us with others. 10This unity soothes the unbearable pain caused by the awareness of our mortality, separateness, and helplessness before the forces of nature and society.This need for a union, through sex, drugs, conformity, creativity, or love, is a basic psychological need, for an experience of aloneness without union leads to insanity-the alleviation of separateness by a total withdrawal from the world.Of these solutions to the problem of human separation, love is the most satisfactory answer.

The Role of Love in Medicine
Love, therefore, is not only ethically required for the practice of medicine, and practically required for effective healing, but existentially required for our own well-being.Love, like medicine, and like life, is an art.Love, like medicine and life, requires an active way of being that no one can teach us, but can only be experienced by and for ourselves.Practicing love, like any art, requires the discipline of an athlete, the concentration of a surgeon, the patience of a child learning to walk, and an attitude of supreme concern, in every moment.
Loving presupposes we have attained a productive orientation in our lives, and have overcome our dependency, our narcissistic omnipotence, and our wish to exploit others.Loving requires humility based on an inner strength.It requires that we be able to see the world as it is, rather than only in the terms of its use or threat to us.Love is an act of faith-based on experience--in ourselves, in another person, and in humankind.
Finally, love requires courage, to judge certain values to be of ultimate concern, to stand by them, and to risk pain and disappointment.
Love is not something we can consciously will, but can experience only by meeting the above prerequisites.We cannot legislate care; But we can nurture it in others and practice it ourselves.Our training can address care and explicitly value it as the most important element in the practice of medicine.Caring role models can provide valuable guidance and inspiration.We can elicit our caring by placing ourselves in the proper environment; we experience care working closely with patients, especially the young and the dying.We must practice good self-care-satisfy our needs-so that we may experience the enrichment which loving brings.Caring for others and for ourselves are parts of the same process.
Regardless of our personalities and needs, caring for others is essential to our well-being.If we are to feel fulfilled in our lives and work, we must understand intellectually its importance and make a life-commitment to practice the art of loving in our practice of medicine.

Our Profession Can Harm Us
Entering medicine is dangerous.The extent of physician impairment, as manifested by substance misuse, including alcoholism, other mental illnesses, divorce, and suicide, is greater than in the general population.Male physicians have 40% higher rates of suicide than the general population, and female doctors have rates of suicide up to 130% higher. 1112.9% of male physicians and 21.4% of female physicians meet diagnostic criteria for alcohol use disorder. 12This is partially because of the personality characteristics we bring with us to medicine, as well as the inherent stresses of our work.It is also a result, however, of the inhumane and negligent treatment we receive from our profession.It is critical that we understand the forces that can hurt us, so we can cope with them most effectively.
As modern medicine, with this biomedical orientation, neglects the well-being of the patient in its desire to cure disease, so it neglects the well-being of its members in its desire for their complete devotion.Medicine encourages personal imbalance through self-denial, neglect, and self-sacrifice.Broadhead and Coombs have documented that the harm caused by "the untempered influence of professionalism" induces a change in motivation from an initial altruism to a concern for self and family, pecuniary gain, individual autonomy, and professional prestige. 13raduating students are less creative, more conservative, more homogeneous, and more cynical than those who enter medical school.The excessive demands of training encourage obsessivecompulsive coping techniques that hurt our ability to have close relationships with friends or patients.

Blame and Shame
Our socialization is in some ways "punishment-centered".Because of our dependence upon our profession for our training, our degree, and a license to practice medicine, we must risk blame, criticism, humiliation, ridicule, even condemnation by our colleagues and superiors.Too often, we let fear of failure and intimidation motivate us.The combination of these stresses and our dependency stimulates the "Patty Hearst Effect", in which we "identify with the aggressor", escaping pain and gaining acceptance by conforming.While this process of professional socialization is beneficial in that we become doctors, it is harmful in that it may hinder our becoming who we are.

Medical Machismo
In our socialization, teachers and colleagues pressure us to bury our humanity and adopt the "Medical Persona."We feel the pressure to develop our Medical Machismo -to strive for perfection, to be strong, to conceal our weaknesses, and to never reveal our troubled feelings.We are, dehumanized by these expectations, just as we dehumanize our patients by expecting them to be trusting, unquestioning, undemanding, incurious, emotionally controlled, stoical, easily diagnosed, and curable.
This "John Wayne-ism" fosters arrogance, pressures us to be decisive (resulting in over certainty), and prevents us from being genuine and close to others.Instead, role models teach us to detach ourselves from the patient and isolate ourselves in a cloak of "Professional Objectivity."Affective Neutrality is valued over self-disclosure, genuineness, and warmth.We are often not taught effective communication skills, or encouraged to understand human nature and the human psyche.As a result we neglect the social, psychological, and interpersonal aspects of illness and healing.The doctor-patient relationship is then sterilized of its potency for healing.
Detachment occurs, in part, because we work so close to death, and deal with such tremendous pain and tragedy.We lessen our pain by separating ourselves emotionally.Since the demand for denial of our emotions prevents us from working them through, detachment becomes our primary coping method.
Our superiors teach us to deny our uncomfortable feelings from the moment we enter anatomy lab.Instead of coping with feelings, we intellectualize them.Often, we avoid resolving our suffering and instead use inappropriate coping techniques to numb or prolong it.We not only learn insensitivity to ourselves but to others as well.As we fail to deal with the emotional impact of our work, so we fail to deal effectively with the emotional impact of our patient's illness.Our ability to empathize atrophies.

Technical focus
Rather than nurturing caring in our training by valuing it as the most important element of medicine, and by immersing students in a caring environment with caring role models, the training system largely neglects it.We are first immersed in science taught by basic scientists.On the wards, where according to one study, attending physicians spend an average of 14.73% of their time with patients, they stress scientific competence over caring. 14Our profession rewards us not so much for our caring as for our crisp presentations, our command of the facts, and our technical expertise.
While medical schools treat medical students and residents more humanely than 40 years ago, the continuing inhumane demands of our training system virtually eliminate our ability to practice the art of caring and, as a result, experience the greatest reward of our work.This is in part because the system hurts us.Overworked, we learn to resent each new patient, who symbolizes another deprivation of our needs rather than an opportunity to practice our art."Professional Objectivity", and an enormous workload and too little time separate us from our patients.
Financial pressures and high work demands allow us less opportunity to experience caring through close contact, and the rewards of giving.Since caring is a concern for the well-being of all, including ourselves, and since our role models teach us selfdenial and neglect, we are taught not to care for others.Since knowledge, the basis of faith, is essential for caring, our lack of self-awareness, exploration and insight also prevents us from caring.

Anger
It is understandable that most of us feel anger.This is natural and justified; our expectations are not being met and we are being hurt.It is essential, however, that we work through our anger and, while recognizing the harmful parts of our training, accept the system, just as we must accept ourselves and others.No human work is perfect, including medicine.
There are good reasons our system is as it is.One is its evolution from the mechanistic era of Newtonian physics in the 17th century, when authorities only allowed anatomists and physicians to dissect if they left the issues of mind and spirit to the church.
Engel considers this to be the source of our current biomedical orientation.The fantastic success of the scientific method, and the resulting belief that science can solve all problems, have spurred this approach to healing.During the early part of this century, our profession experienced increasing competition with other forms of medicine, and responded in part by elevating the doctor's status to an elite level; with this elevation, training became more demanding, and unfortunately more inhumane.
The achievements of modern medicine are among the greatest of humankind.While there is much that is wrong, there is also much for which we can be grateful.With understanding, acceptance, and faith, our anger becomes manageable, so that we can join and improve medicine, and practice our care not only for our patients, but for those who hurt us.

Self-Care
Take Control We can best care for ourselves by knowing who we are, what our needs are, and then taking responsibility for satisfying them.We must remember we are free to choose to live life as best fits us.Only we can decide what is best for us and strike the many necessary balances accordingly.When you feel discouraged or conflicted, remind yourself of your values and why you decided to become a doctor.

Make Self-Health a Priority
We can only care for others as we care for ourselves.To teach health, we must practice it.The healthy person balances work, love, and play.Make time for rest and exercise.Eat a healthy diet.We are doctors, but are more than doctors; we must attend to all our needs in a balanced way.This requires setting limits on our responsibilities and selfexpectations, pursuing our non-medical interests, and making time for other activities outside of medicine.

Explore Yourself
Discover your feelings.your needs, your strengths, and your weaknesses.Develop ways to be with yourself, such as exercise, walks, meditation, or listening to music.Keeping a journal is not only an excellent technique for selfdiscovery, but can also enrich the experience of life.Practice selfhonesty and try to understand why you feel as you do.Try not to be afraid of what you might find.Practice a moment-to-moment mindful self-awareness in your daily living.

Accept Yourself
We are all okay, independent of who we are or what we do.We must also accept that we are imperfect, and that we all have a darker side that fears, feels anger and aggression, or wishes to exploit others to meet our needs.Accept that you have personal limitations, that you cannot do and be everything you would like; this will help you have realistic selfexpectations that save you from disappointment.

Find Good Role Models and Mentors
Seek out those whose values match your own.Remember that human qualities are far more important in our work than anything else.Work with those whose personal qualities make them effective healers; those who treat both their patients and you with respect and care, who are not afraid of being close, who addressed the patient's suffering, and who value you for who you are without condemnation.
Maintain Your Relationships Stay involved with your lover or spouse, friends, classmates, and family.Even though our careers may compromise these relationships, we must never sacrifice them, as they are essential to our well-being.They provide us with support, with opportunities to care, and with the experience of closeness so essential to our work.

Work on Your Interpersonal Skills
The more effective we are in our interactions, the more rewards we will experience in our work and lives.Take counseling classes.Practice acceptance, nonjudgment, and empathy.Practice listening.Develop an understanding of such processes as transference, projection, denial, and displacement, and learn to recognize them in yourself and others.

Learn to Cope Well
When pain comes, learn to recognize it, and attempt to understand it.Take breaks from what you're doing, remove yourself from a stressful experience for a time to work things through.Hash things out with people you trust.Be open to recognizing the parts of yourself that cause you pain, and to changing them.Take care of yourself.Do not deny your pain, work harder, self-medicate, or abandon relationships.
Read Attempt to understand the process you are immersed in.The references at the end of this article are all invaluable.

Join a Support Group
Not only do groups help us deal with what we are going through, they also provide us with an opportunity to be close to colleagues in a supportive, acceptant, non-competitive way.We can practice being who we are with others in a safe setting.If we have difficulty being close to others, this is the ideal setting in which to develop this ability.The experience of closeness and caring is in itself rewarding.

Get Help
If you feel you could benefit (and most of us can), get good counseling or therapy to work on your personal life issues.Shame or embarrassment not only indicate a lack of selfacceptance, but are inappropriate given that all people have problems.Also, refusing to receive help for our suffering is inconsistent with helping others with theirs.

Make Changes
Do not feel inhibited about trying to make changes.Talk to the people in charge when you are upset about something you feel is unfair or inappropriate.Become politically active, work with committees, write articles, or circulate petitions.
Practice Medicine, and Life, as an Art The practice of any art requires discipline, concentration, patience, and supreme concern.Remember that no great reward comes in a day, but neither will medical school last forever.With patience, you will reach your goals.Like Osler, practice living each day to the fullest, concentrating your awareness on the details of each moment.Life is not so much a goal as a process; the quality of our experience lies in our attention first to the process, and second to our goals

Conclusion
Medical training is a crisis for all medical students and new physicians because we must change our entire identities, endure many stresses, and meet heavy demands through hard work.The Chinese symbol for crisis is the superposition of the two symbols for danger and opportunity.Medicine is hazardous to our health, as evidenced by the current tragedy of widespread physician impairment.But it is also an opportunity for us to grow in ways which enhance our fulfillment.Being a physician is a privilege that, for all its hardships, brings us many rewards.By understanding our own needs, the process we are undergoing, and by practicing good self-care, we can avoid the dangers along the way as we become physicians who experience meaning, fulfillment and satisfaction in work and life.

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It is more important to know what kind of patient has the disease then what kind of disease the patient has." -Sir William Osler