'Six things I wish I'd known when I became a doctor'

Our guests this week are physicians who will share the six things they wish they had known when they started practicing medicine.

THE LISTS FROM OUR ROUNDTABLE:

Craig Bowron:

I wish I'd known...

1. How far the pendulum of "standard of care" swings in medicine. The best available evidence always seems to be changing. Accepting this makes you a less dogmatic doctor. Don't browbeat your patients. It's their life.

2. How emotionally and personally intense the job is. A lot of people have stressful jobs, but there's nothing more threatening than not feeling well.

3. Medical training focuses on treating illness, and very little on how to stay healthy — exercise, sleep, nutrition, weight control. Physician, teach thyself.

4. How important storytelling is: People don't necessarily expect to be cured, but they do expect to be heard; they do expect you to get their story right.

5. Pace yourself: It takes a good long time to get good at this. The science you can look up; the art you have to learn. Science is complicated. People are more complicated.

6. How much of being a doctor is helping your patients understand risk. How do you apply population-based data to any individual?

Meghan Walsh:

I wish I'd known...

1. Keep your patient at the center — in this ever-changing health care environment, your patient will remind you of why you are in this profession — even as the rest becomes more and more challenging or unfamiliar.

2. Find a mentor and know your allies from your confidants.

3. Take the time to reflect alone, with your students, and with your peers — model it, believe in it — to err is human, learn from it and share what you have learned.

4. Save some emotional energy for your family — it is easy to deplete your reserves at work. Recognize when you need a break or when burnout is creeping in.

5. Recognize the patterns you set early — they quickly can become engrained: nurture relationships, take care of yourself, remain curious, grow.

6. Medicine is a team sport — you won't have all the answers and shouldn't expect to. The more you learn, the more you realize you don't know.

Jim Pacala:

I wish I'd known:

1. Just how fulfilling a medical career would be. I always thought being a doctor would be challenging, stimulating, and rewarding — that's why I became one. But I was unprepared for the nuanced complexity of the challenge, the constant and renewing excitement of tackling new problems, and the depth of fulfillment and satisfaction in providing care. I really enjoyed my intern year, and have enjoyed being a doctor more and more each year since. I have come to relish the humbling experience of being a doctor — reflecting on what I don't know and don't understand as much as what I do know and understand.

2. That good medicine is less about knowing the right answer and more about how one gets to the answer. At the outset of my career, I thought that the primary task was to "learn" medicine — commit all the anatomy, physiology, pathology and therapeutics in a concrete factual way to my brain. Then I'd be "right" all the time when I took care of patients. I have come to realize that developing a process for working through a case, a process that gathers information and considers it in concert with the patient to arrive on a course of action, in a manner that accounts for the limitations of human error, is much more important.

3. That the social context of medical care is even more important than I thought it would be. One of the main reasons for my interest in medicine was the realization that it went beyond science to involve actual people who were individuals with their own social identities. But it wasn't until I began taking care of patients that I realized just how important it was to understand them as individuals, and how their beliefs, behaviors and background contribute to medical outcomes.

4. That the political context of medical care is more important than I thought it would be. I did not think much about policy and politics when I first became a doctor. Over the past 25 years, I have come to appreciate how the political process profoundly shapes how medicine is practiced, which discoveries are made in research, how we educate doctors, and how medicine influences the health of the population. I have also come to appreciate that health care policy isn't always based on science or facts.

5. That the economic context of medical care is more important than I thought it would be. Much as I was blissfully idealistic and naive as a medical student in the 1980s, I held to the notion that money wasn't going to influence anything I did as a doctor. The ugly truth is that is does, in complex, direct and indirect ways. For me, I don't think it had as much to do with my choice of specialty — family medicine and geriatrics are among the lowest paid specialties (although I get paid quite enough for what I do) — but now I understand much better how the financing mechanisms of health care shape the way medicine is practiced and influence the decisions I make when providing care for my patients.

6. Just how amazing the things I saw in my career would be. I lived and worked through the AIDS epidemic, a profound era that is largely lost on medical students today. I have seen the sequencing of the human genome and its potential to benefit — and harm — humanity. I work with patients and colleagues who have had transplants to cure conditions that would have been swiftly fatal 25 years ago, and if you saw them walking down the street, you wouldn't know they had ever been sick. I have seen life expectancy in this country increase by four years since I started medical school; that might not sound like much, but it is a remarkable national accomplishment. But for every one of these successes, there are seemingly just as many failures. We have so much more to do, and that is why I look forward to the rest of my career with as much excitement as I enjoyed during the first part.

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