Like a post-term baby coming into the world days after its expected arrival, I entered the profession of medicine late. I was not one of your traditional medical students who had known since a young age that they would be doctors. I was accepted into medical school at the ripe age of thirty-two, after nine years of working as a children’s theatre actor, a youth volunteer, and a high school and middle school teacher.

Because of these life experiences, I never felt that I was the conventional “programmed” medical student or resident. Doctors in training, as a result of the competitive nature of medical school acceptance, have had to be extremely disciplined and focused for many long years. But for many of them, the narrowly focused premedical curriculum and the pressure to start the long years of medical training as early as possible have robbed them of the opportunity to take courses outside of the sciences and the chance to have other life experiences. It is interesting to note that many medical schools do not require an applicant to have a college degree to be accepted; all that is required is the completion of the premedical curriculum, which can be accomplished in two to three years. In addition, there are a number of combined college-medical school academic programs that grant a bachelor’s and medical degree after seven years of study, effectively eliminating one year of academic life. This academic and career mindset, although it may help these students master the basic science courses needed for admission to medical school, does preclude many from having broader and more diverse experiences outside of medicine.

I clearly remember my first day at Rush Medical College. The younger students in our class seemed edgy and restless, as if they wished to be somewhere other than medical school at that moment. A couple of these students even commented to me that they wished they had taken a year or two off in order to see the world before entering medical school or had had employment that would have given them an experience other than medicine. The older students appeared more relaxed—unfortunately, grayer—and like me, they seemed to be wondering more if they would be able to get their atrophying brains around the enormous amount of material we had to learn, and further, if they would have the physical stamina to finish medical school and residency. At that moment, we were not looking to travel the world or have jobs outside of medicine, for many of us had already had these experiences and some had even had several prior careers. We were here because we had chosen to be. My life experiences, expectations, and hopes would profoundly influence the way I viewed every aspect of my medical education.

I did not enter medicine for the money. I was living adequately at the time on my teaching salary. I also did not go into medicine to satisfy a large ego—the innumerable theater and film audition rejections I had received during my four years as an actor in Chicago had gone a long way towards humbling me. I became a doctor for two reasons. The first—and incidentally one that is found on almost all medical school applications—was my desire to help heal people. Learning the skills that could help cure or lessen a person’s physical and mental ailments and thereby relieve his suffering and despair was—and still is—important to me. These medical skills could also be used universally, and the idea of having a career that filled a global need intrigued me.

The second reason I became a doctor, one that, on account of the conservative environment of medical education, is rarely seen on medical school applications, was my desire to use the profession of medicine to effect social change. Doctors are given an enormous amount of respect in our society—when physicians speak up for the human condition, it can have a powerful influence on others. In this arena, during my course of study, my idols became Dr. Albert Schweitzer and Dr. Quentin Young on the international and national levels, respectively. On the local level were my advisor and mentors, Dr. Maria Brown, Dr. Fred Richardson, and Ed Eckenfels. Each was profoundly concerned with the human condition and dedicated to social justice; each took considerable professional risks challenging society’s and their own institutions’ prejudices while championing progressive causes. These doctors, and many not mentioned, have courageously used the power of their profession not only to call attention to the inequities of the world, such as racism, sexism, and lack of affordable healthcare, but also to begin the important task of righting these wrongs. I was fortunate to find these altruistic professors and mentors while in medical school who helped me strengthen my resolve to try to effect social change.

I had become interested in medicine several years after college while working with inner-city youth in Chicago and eighth grade students in East Palo Alto, California. Through them, I witnessed the paucity of available healthcare for disadvantaged students and their families. During these years, I spent a good amount of time outside the classroom “patching up” injured students’ scrapes, bruises, and sprains with my emergency medical technician (EMT) skills. For many of them this would be the only medical attention they ever received. I noted other more serious injuries, such as displaced fractures and lacerations, and chronic conditions, such as asthma, obesity, and depression, all of which went unattended. It was sobering to come face-to-face almost daily with the lack of preventive medical care available to these youths, and the need for healthcare workers in disadvantaged areas became increasingly evident to me. At this point I set my sights on medical school.

From my work as a teacher, I was schooled in the belief system that education, like other social services, is guaranteed for all. From my work in both private and public education, I was keenly aware that vast inequities in educational opportunities exist in this country, but that even with these disparities, a minimum quality of education is guaranteed through high school for all.

I entered medicine believing, perhaps naively, that healthcare, if the providers were available, would be available to all. However, my intern and residency years awakened me to the vast discrepancies in our country’s healthcare system and, more important, to the fact that healthcare, unlike education, is not available to all.

In fact, America is the only industrialized nation that does not cover all of its citizens with health insurance, and this lack of insurance has been detrimental to Americans’ health. For example, our country’s infant mortality rate, which has been shown to be a good marker of the health of a nation, is the highest of all industrialized nations; seven of every one thousand infants born in this country die before reaching their first birthday. When we compare our infant mortality rate with that of other countries (Japan with four, and the United Kingdom, Germany, and Canada with five for every thousand infants born), we see the strong connection between health insurance and health outcomes. As Drs. Himmelstein, Woolhandler, and Hellander have noted in their book, Bleeding the Patient: The Consequences of Corporate Health Care, the U.S. has the lowest prenatal
care rate of any developed nation; 18% of all pregnant women and 28% of pregnant black women fail to receive prenatal care during their first trimester (no other wealthy nation has a rate higher than 10%). The number one reason for this delay in seeking prenatal care cited by women who know they are pregnant is their lack of health insurance or money.

And despite the fact that we spend two times as much per capita on healthcare in this country as compared with Germany, Canada, France, and Japan, our country’s health has dramatically worsened. Dr. Himmelstein and his colleagues observe that between 1960 and 1997 our infant mortality rate ranking, compared with 29 other industrialized nations, dropped fromm12th to 24th place. During this same time period, our women’s life expectancy slid from 13th to 20th place, and our men’s life expectancy fared equally poorly, falling from 17th to 22nd place among these same 29 nations. The physical consequences of being uninsured are very real: the mortality rates for uninsured people have been shown to be 25 percent higher than those for insured people. This equates to roughly 18,000 adults dying each year because they are uninsured and cannot obtain adequate healthcare. Finally, as the authors of Bleeding the Patient note, the irony of our healthcare system is that there are no uninsured legislators. However, 12 percent of all healthcare workers (including doctors), 7 percent of teachers and university professors, and greater than 10 percent of the clergy are uninsured.

I wrote this book primarily to educate. Growing up in a household that had a reverence for education and teaching, from my first formative years until I emerged from graduate school, I was continually immersed in the importance not only of obtaining a good education but, more notably, of striving to be a good educator in the profession I chose. Commencing with my grandmother, an elementary school teacher, through my father, a college professor, and down to my siblings, who are educators, I have been surrounded and nurtured by people in the field of education. These life experiences, some as mundane as daily dinner conversations as a child and adolescent, to the many opportunities to learn from my students when I was a teacher, have left an indelible imprint on me of the importance of conveying information to others.

This primary desire to educate led me, during the final part of medical school and the intern and second year of my family medicine residency, to write home and share with my family the experiences that are in this book. I would be less than forthright if I did not also admit that during these years I wrote for my own mental health. Medicine is a complex profession; its body of knowledge is vast and detailed, covering everything from the subatomic particle to the multifactorial causes of the diseases of the body and mind. As well, it exposes its caregivers to all the glories and tragedies of life, yet it seldom offers these same caregivers the simple time or space to process or debrief after these experiences. Writing home was a chance for me to start to make sense of all that I experienced as an intern and resident.

This book is not an attempt to tell my experiences as a typical doctor, as many others have done; this is not my place in life. Nor is this book my effort to record, in an anthropological manner, my story as a doctor who came to medicine later in life, for this, too, has been articulated by other doctors. Rather, this book, since it was originally a series of letters that I wrote home, is my endeavor to tell my story as a doctor from a very personal point of view. My professional and personal experiences, many of which happened before matriculating into medicine, while others happened while I was in training, have allowed me, for better or for worse, to look at the profession of medicine from an angle not ordinarily seen. This viewpoint, I hope, will be both informative and interesting for the reader.

Starting with Chapter One, which relates an event that happened during my fourth year of medical school and helped confirm my desire to be in primary care, and continuing with cases encountered during my intern year and second year of residency—these writings are mostly about my patients. It is my hope that their lives, and my experiences with them, can offer a window into the training of a doctor, the profession of medicine, and a glimpse at our nation’s healthcare system.