Do you feel that your education is compromised by service?

As a residency program director, this is the question on the annual Accreditation Council for Graduate Medical Education resident/fellow survey I dread the most. When I read personal statements from applicants, they all speak of choosing medicine as a path of providing service to people or for a higher purpose. When did the term “service” become something detrimental that interferes with our education and ambitions?

It reminds me of a time when I was in medical school. I was on my first rotation as a third-year medical student, sentenced to 4 weeks on the “malignant” pediatric surgery block, and quickly feeling as I anticipated—like the lowest rung on the ladder. No one seemed to care who I was, where I was, or what I was learning; but like many experiences, sometimes our greatest life lessons come when least expected.

The surgery service was rounding on a premature newborn in the neonatal intensive care unit. The baby not only had immature lungs, but also had a tracheoesophageal fistula and required extracorporeal membrane oxygenation. Her small room was filled with huge machines and an intricate network of tubes, wires, and monitors, whose beeps and alarms served as a constant reminder of the technology that was keeping her alive. When she began to decompensate, the surgery team arrived to repair her fistula at the bedside.

I stood at the periphery watching the instrument tables roll in and the surgeons gown up and transform the patient's room into a functioning operating room. They began their meticulous procedure. All was quiet until I heard some scuffling and an exchange of words, followed by the chief surgical resident moving back from the table and angrily stomping away.

“You!” the surgeon said as he looked in my general direction. Was he talking to me? I had worked with him for nearly 4 weeks. He didn't know my name. I knew his name—in fact I remember it to this day. “Put on a gown and get in here.” I looked around to see if he was talking to someone else. “I need you in this space, to retract.” A nurse helped me on with a gown and pushed me forward until I saw the space I was supposed to be in—it was tiny, barely a square foot, and surrounded by a web of wires. “See all these wires?” the surgeon barked, “If you move an inch, this baby will die.” I squeezed into the corner, a miniature retractor in hand, my arm twisted completely behind my back, and did what was asked of me. At one moment of weakness, I craned my neck to sneak a peek at the surgical field, and the surgeon snapped, “Stay still—I didn't choose you to do this for the experience! I chose you because you're skinny!”

So this is what it came down to: struggling through organic chemistry, memorizing the Krebs cycle, hospital volunteer work, student loans, the noxious smell of formaldehyde, board exams—just so I could be this anonymous skinny person facing a wall and retracting. It was grunt work. It was a scut. My education had been “compromised by service.”

I have learned since then that most days in medicine you are valued for your brain, your thoughts, the way you link basic science and clinical clues and elements of your exam to come up with a diagnosis and a plan. Some days you are needed for your ability to reduce a fracture and relieve pain or to supervise and teach a trainee how to do it independently. Some days your job is to tell a family that their child has a terrible disease and to ready them for the long course ahead, and some days it is to tell them their tests are normal, and they will be fine. Those are the things we have trained for, that make us feel the true weight of our worth in this field.

But there are other times when you are needed to run a CD down to radiology or complete FMLA paperwork or fax prescriptions to a pharmacy or redo a home health order for the tenth time since you still didn't get it right. It's not the glory of the job. It's not even close. But when you take a step back and see how that piece fits into the bigger picture, you may have indirectly avoided an additional x-ray, or prevented a mom from losing her job while her child recovered from an illness, or decreased the pharmacy wait time for a family that is already exhausted from a long hospital stay. Or you may have helped clear the field for a surgeon to sew up a tiny fistula. We are providing a service, in the most noble and altruistic definition of the word.

I often think about this experience, my initial disappointment as an insignificant student holding a retractor, reframed over time, as pride in being able to help a fragile infant survive. These moments of retracting and faxing shrink beside the opportunity to witness bedside miracles, the chance to play a part, no matter how small, in the health of a child, and the privilege of being a part of this profession dedicated to service.