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Many self-elected cognoscenti refer to the residency years of postgraduate medical education as dehumanizing. They cite schedules so demanding that they leave no time to eat or to sleep, a diminution of sensibility, a loss of compassion, a turning inward, a turning away, and this relentless responsibility for the patients who will be in the resident's care. Surely this must be withering to the spirit, they say.

But instead of being dehumanizing, the residency years are, in fact, deeply humanizing because of what I call "the time warp concept." The patient suddenly worsens and the resident goes into an astonishing and selfless time warp. Once the patient is better, or at least stable and in safe keeping, the resident realizes he or she missed a meal or two and hours of sleep and maybe, and importantly, a telephone call home. But my hypothesis is that fatigue and fatigue-related errors go on hold in the mystery and transformation of this time warp.

Residents are not counting widgets, but are engaged intellectually and emotionally, focused on the other—the patient. The resident is no longer a student doctor, but rather the doctor. It is at this time the resident learns about people to a depth and complexity that probably is revealed to very few others, except maybe members of the clergy. Patients and their families show the doctor deep wells of courage, generosity, humor, joy, and true, true goodness. They also show depths of despair, desolation, and sadness; and anger, distrust, breathtaking selfishness, and astounding hatefulness.

But the resident becomes sensitized to the patient's behavior and is enriched by these experiences. The resident becomes more professionalized and more human. The resident refines his or her understanding one patient at a time. Talking with a patient is not like talking to anyone else. This is a unique relationship that needs respect. The patient hasn't come to make a new friend, to simply get acquainted, or to flirt, for that matter. This person has come to the doctor because he or she doesn't feel good. He or she may be sick and hopes, very much, the resident will help. Some patients, of course, are hoping for cures. Some, knowing there are no cures, still hope the resident will help them feel better. Patients soon learn from the resident that he or she cares. And that is from the way that the resident pays attention and listens.

And, indeed, when the white coat comes off, the resident has the opportunity to use the gifts patients give, the gift of living deeply in the other parts of life. During this period, residents may find it takes much more to experience sadness and much, much less to make them smile. So as friends and loved ones seek sympathy and attention—a sudden, unexpected lost job, a new debt, a bad boss or just a plain bad day—the resident may suddenly have a flashback to the mother who just learned from the resident that her child is seriously and desperately ill. And so in these years, the resident learns to use one set of weights and balances when in the white coat as a physician and one for the person when the white coat comes off and the resident is with loved ones.

These residency years, a decade for some, offer the opportunity for self-definition. In this time, the resident learns those special skills he or she practices for a lifetime. Some residents choose to care for patients one at a time. Some choose to pursue the discovery of basic truths doing research at the bench or at the bedside. Some choose to stay at a medical center for the humbling privilege of teaching in an arena where the questions and the answers are always changing. Some make a difference to the underserved in under-resourced areas of the world, which includes part of our own country. And some choose to work on health policy, perhaps trying to jettison the corporate metaphor and finding a new metaphor that actually works.

And though it takes a lifetime for the resident to become the doctor he or she wants to be, these years are truly the beginning of the process. Rather than being an overworked and overtired robot as some suggest, the resident learns the most valuable lesson of a doctor's life—what it means to be a human being in need and what it means to help.

This POV was adapted from the keynote speech Dr. Glenda Garvey '69, professor of clinical medicine, gave to the P&S 2002 graduating class.

Have a Point of View you would like to share on a topic relevant to the In Vivo audience? Contact the editors at invivo@columbia.edu.


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