The first thing is, thank you. Thank you for taking AP Biology. Thank you for memorizing medical school. Thank you all for choosing to spend some of the best years of your lives in this hospital. You didn't have to. There are so many other ways you could have chosen to spend your time and talents. That you are here instead says so much about you.

I spent a recent morning watching a sonogram with my wife and our 2-year-old daughter. The baby has a name, and she's kicking like crazy. And my 2-year-old—she's really into the idea of being a “big sis-tur.” She does this thing where she walks over and cups her little hands on my wife's belly and shouts, “Talk, baby! Talk!” This is what is known in the toddler community as “bedside manner.” I admit I have used the same technique at work.

Anyway, everything is going great, except this 1 little detail that keeps nagging my wife and me. On our very first ultrasound at 16 weeks, the physicians noticed an abnormality of the umbilical cord. It is the kind of thing that 99 out of 100 times means absolutely nothing, except that's not how the human mind thinks. Ninety-nine out of 100 is a statistic that is eminently reassuring to physicians, but not to ordinary humans.

Ordinary humans. Now there's a distinction you've never had to make. But you will. Medical training is already changing you. It is altering the way you speak, the way you think, and the way you feel. The trouble is, you can't be a good physician if you forget what it is like to be human. The real art of medicine is a kind of code-switching: an attentiveness to, and a fluency in, 2 very different tongues. It is the capacity, as the neurosurgeon Dr Richard Rapport put it, “to jam into the same mind an industrial worldview and a humanistic one.” And finding this balance is much more than a luxury. It really is the only way to stay sane in this line of work.

But for now, you can all relax. You can all relax because simply having matched into your residency programs guarantees so many things. The training will do what it is designed to do. It will challenge you, and it will change you, and you will rise to the occasion. And when you are finished, your mentors will certify that you are competent to carry the torch of this profession, and you will feel like you have made it. Except here is the deepest secret: competency is not everything. In fact, it is barely the beginning.

The things you will experience in the coming years are the same things physicians have always experienced. Everyone will quake at the base of the same steep learning curve. Everyone will lose sleep. Everyone's relationships will become strained in some way, and some of them will break. Every one of you will lose something. And many of you will find that those losses pale in comparison to the things you will gain.

In the coming year, every one of you will feel like a success, and like a failure. Every one of you will feel scared and overwhelmed, and you will get through it together. Your patients will die, and you will write their death summaries, and you will cry with their families. Just by showing up every day, these things are guaranteed. What is yet unknown, what you will have to discover, is what these experiences will mean. Meaning, after all, is something you will have to make.

To paraphrase David Foster Wallace, meaning does not flow directly from experience,1  meaning is not something you can take for granted. Finding meaning in your lives and in your work requires effort. More than anything it requires attention, and attention is a choice you make every day. How will you choose to focus your attention? Will you focus on all the notes you have to write, on the fact that this is the third case of cyclic vomiting syndrome you've seen this week? What about the fact that this patient, this person consumed by suffering, is also a single mom, and her biggest concern at the moment is who's going to make sure her kids eat dinner tonight?

See, the way you choose to focus your attention matters deeply. It colors everything.

Wallace warned that, under conditions of extreme stress, your curiosity and your open-heartedness will give way to a steely focus. Reflexively, your attention will shift from the vast, chaotic, frightening, beautiful world outside, to something that feels more manageable. To more mundane details: electrolytes and progress notes. The computer screen, instead of the window. Things you think you can control. Day in and day out, this narrow perspective becomes routine. It becomes what Wallace called our “default setting,”1  and it shields your eyes from a world of meaning.

This may not quite resonate in July of your intern year, when you are still closely in touch with the world beyond medicine. The world of ordinary humans. But one's perspective changes so quickly. And by February, it is entirely possible that you will come home from work on a Tuesday evening, and you will fling your coat and your keys on the table, and flop on the couch and hear yourself say, “My patient cried in front of me today and I didn't feel anything. I didn't do anything. I just turned and walked away.”

Now that sounds grim, and it is meant to. It is also the truth. On those days when you feel that dark and heavy, it will be easy just to check out. Don't check out. Don't believe you can steel yourself against all of those prickly things without missing all of the good ones as well. You can't go on muttering about this “train wreck” and that “pain seeker” and expect to feel gratified by your work. And neither can you go around pretending that everything happens for a reason, or that things will always work out. The best you can do is to keep your eyes open, and be honest with yourself.

No doubt, you will struggle to find meaning, to find balance, to find joy in your work every day. And you know what? You will. Many of you will. You will love this profession, love being a physician, love what you mean to your patients. And when you find yourself struggling, go back to the beginning. Remember the heart you poured into that original personal statement. Remember how much you meant it. You pledged your life to a profession, at the center of which are a whole mess of imperfect and inspiring humans. Commit to the work it takes to find and to hold that center, and hold fast.

David Foster
in his own words
Intelligent Life
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