A Clinical Life — thirty years at the bedside, the formation of a physician, and the case that opened the door.

1. Medical school as a test of resilience

A life in medicine is a daily challenge. It begins with medical school, which is nothing more than a test of your resilience, consistency, and drive — not unlike the hazing you must endure in fraternities or the military to gain your right to belong. The clinical knowledge accrues over time. The clinical wisdom takes much longer. What medical school actually selects for is whether you can keep showing up. The years are long. The material is enormous. The hours are punishing. What is being tested is not how much you know but whether you will still be there at the end.

2. Internship — the quiet year of fear

Next comes internship, where I became a fully fledged doctor with all the rights and responsibilities, yet none of the true knowledge or wisdom to truly practice medicine. These were intense and terrifying times. Every intern lives them quietly, and in fear. The white coat is on. The pager is on. The patients are real. And the inside of my head, in that first year, was a small, constant litany of I do not know what I am doing, recited under the breath of decisions that had to be made anyway. Looking back, that fear was probably the most honest assessment of my own competence I have ever made. The fear kept me careful. The fear kept me asking. The fear is the part of internship the rest of the profession does not talk about, and it is the part that, in my view, makes the rest of the formation possible.

3. Residency — the dangerous education of one's own competence

Residency comes next. A little more experience accumulates, and with it a misplaced sense of competence that leads to clinical misjudgements and mistakes. This is the period where the responsibility to do the right thing is honed in — not by reading, not by lectures, but by exposure to the consequences of my own lack of knowledge and overabundance of hubris. Every resident learns, sooner or later, what the cost of confidence without warrant looks like in another person's body. The good ones learn the lesson early and remember it. The lesson, properly absorbed, becomes the inner check that governs every decision afterward.

4. The attending years and the multi-role burden

Finally, residency ends and the professional clinical world begins — and the pressures of daily practice build up and multiply in a seemingly never-ending progression. On a daily basis, one must be a perfect listener, a keen in-between-the-lines mind-reader, an impeccable diagnostician, an up-to-date literature reciter, a measured prescriber, a conservative observer or an aggressive detective, an appropriate user of resources, an attentive and polite coworker, a prompt responder, a patient teacher, a comprehensive note documenter, a perfect coder, a follower of protocols while at the same time using one's intuitions to learn how and when to break them at the right time. It can get exhausting.

The administrators, I should say, mean well. But they are not at the bedside. They make what are, to them, sound decisions — decisions that look sound from inside the conference room, the policy framework, the budget projection — and they have no way of knowing the detrimental effects those decisions have at the bedside, where the doctors, the nurses, and the patients are the ones who have to live with them. Over the years this becomes another periodic avalanche one has to deal with: a new policy, a new mandate, a new workflow, each arriving with its own justification and its own cost. The cumulative weight of the avalanches is what produces what was, for a long time, called burnout, but which is more accurately described as moral injury — the slow erosion that comes from being asked, repeatedly, to do work whose institutional shape is at odds with what the work is actually for. It takes years off your career's enjoyment.

The institutional pressure has a specific shape that becomes more obvious as a career advances. Clinical guidelines — the documents that define what counts as standard of care — are progressively shaped by Big Pharma's dicta. Medical societies adjust their guidelines to accommodate increasing amounts of drug treatments, and the cumulative result, especially as patients age, is polypharmacy — the patient on twelve medications because each guideline added another, with no one in a position to step back and ask whether the twelfth medication is helping or harming the patient who is already on the other eleven. Inside that environment, the path of least resistance is to follow the imposed guideline rather than question its effectiveness or its relevance to the particular patient in the room. Questioning takes time — time to discuss side effects, benefits, and risks with the patient and the family, time to document the discussion thoroughly enough that the chart will withstand the eventual call from the administrator or the compliance medical director asking why the standard guideline was not followed. Going with the established flow is easier than rocking the boat. The slow erosion the moral-injury reframing names is partly the cumulative cost of seeing this clearly and choosing, more often than one would have chosen at the beginning of a career, to rock the boat anyway.

The business behind medicine is the dark shadow always lurking in the background of these decisions. As the years go on it becomes progressively harder to tease out the real clinical benefit from the economic incentive — whether for a drug, a procedure, or the guideline that recommends both. Honest clinical judgment does not require denying that the incentive structure exists; it requires being awake to it. That wakefulness is itself effortful, and it is one of the things the years of practice slowly train.

The juggling is real, and the dropping of any one ball has consequences. None of it would be sustainable without the supporting family who has helped me, across all these years, keep them in the air without letting them fall.

5. The art of medicine, reframed

It is here, in the attending years, that I came to a small reframing of a phrase that medicine uses often. The art of medicine is normally taken to mean the art of clinical practice itself — the diagnostic intuition, the bedside judgement, the seasoned reading of cases that protocols cannot fully name.

To me, the art refers to something else. The art is being balanced enough to maintain your sanity through the process. The art is the daily, hourly discipline of staying steady inside the multi-role burden, of not collapsing into any one of the roles, of holding patients with care while holding the institution at arm's length when the institution's priorities and the patient's are not the same. The clinical practice is the craft. The art is what makes the craft possible to keep doing for thirty years without ceasing to be the person who began it. It takes a great deal of effort and mental focus not to misdirect institutionally-led frustrations towards the daily engagement with patients' concerns.

6. The arithmetic of a career — the weight, and the work the weight has actually been doing

Clinical life is rewarding and challenging in ways that are not always cleanly separable, and one of the standing challenges is the sheer arithmetic of decision-making across a career — the standing imperative to keep the rate of suboptimal decisions as low as the human nervous system can sustain over decades. Mistakes become unavoidable once you take seriously the order of magnitude of the decisions a physician makes. As a hospitalist I make roughly one hundred decisions per shift, ranging from the trivial to the potentially life-saving. I work fifteen twelve-hour shifts a month, twelve months a year, for thirty years. The arithmetic comes to roughly five hundred and forty thousand decisions across a career. It is not possible to make the right call every time. Anyone who claims they have is either new, dishonest, or both. The corollary every clinician carries with them — and which the institutional culture rarely names — is the steady background presence of the malpractice lawyer, the deposition, and the suit that might one day be brought for one of the decisions that did not go the way it should have. Even when you have done everything by the standard of care and crossed every T and dotted every I in the chart, an unexpected or poor patient outcome can bring the lawyers to your doorstep and keep you entangled and on edge for the next year and a half. The shadow does not paralyse the work, but it is the steady undercurrent that runs beneath every doctor's clinical life — and it shapes every chart note and every conversation with a family in a way no medical-school curriculum had prepared me for.

The other arithmetic, which I have only recently begun to absorb properly, runs in the opposite direction. Roughly thirty to forty percent of the calls and requests in a hospitalist's day are for pain medications, anti-nausea medications, laxatives, and anti-diarrheals — the medicines whose job is straightforwardly the relief of suffering. Multiply that fraction across more than half a million decisions, across thirty years and a population of patients who keep arriving on the worst day of their lives, and the running total of small reliefs becomes a number I find difficult to hold in mind. By virtue simply of having stayed in the job, I am almost certainly one of the people who has done the most concrete relieving of pain and discomfort in human history. None of it feels like much in the moment. Each instance is a phone call, an order placed, a prescription written. The pattern is only visible when you look back. And when it does become visible, it answers a question I thought I had given a cliché answer to in a medical-school admissions interview many years ago: why do you want to be a doctor? Whatever ambition or curiosity or duty was in the answer at the time, what has actually been done, in the end, is the relief of a great deal of human suffering, one quiet order at a time.

7. The patients who stay with you

There are patients who stick in your mind even after many years and thousands of clinical encounters. Some you remember because of your mistakes and what you learned to carry forward from them. Some because of the unfairness of the situation — the cases where the world gave a person more than the world had any right to give them. And some because they became unexplainable under the usual bio-medical expectations — cases where the body did something the body was not supposed to be able to do, or where what survived in a person was something that the chart, the imaging, and the standard physiology could not account for.

The patient who has stayed with me most, more than any other, is in the third category. She is also, more than any single case in my practice, the one who opened the door.

8. Mary Parker — the case that opened the door

Mary Parker was a young aerobics instructor who arrived in fulminant septic shock and multi-system organ failure from meningococcal meningitis. By any conventional reading of the clinical numbers in front of us, she was not going to leave the hospital. The physiology was that catastrophic. We did the work because that is the work, and we did it with the muted expectations any clinician learns to carry into a case that bad.

She survived.

She taught me, first, that a young, healthy body can overcome unthinkable physical insults and come back in triumph — that one should not give up too soon on a young fighter. She taught me, second, what courage looks like during recovery: not the dramatic kind, but the daily, patient kind that returns to the work again the next morning. And she taught me, third, the willingness to keep fighting on her own for her family in the aftermath of four limb amputations and every-other day hemodialysis — a kind of resolve I had read about in books and not, until then, witnessed at first hand.

But there was something else she taught me, and it is the something else that opened the door. Mary Parker taught me the normally hidden and unexplained abilities of consciousness to survive impossible physiological odds intact. The numbers said her brain should not have come back as herself. Her brain came back as herself. What returned was not a damaged approximation. It was Mary. And what returned with her was a question I did not yet have the vocabulary to ask: what is the relationship between the substrate and the person? Standard bio-medical training had given me an answer to that question, and the answer was that consciousness is what the brain produces when the brain is intact and which dissolves when the brain is not. Mary Parker did not fit that answer. I did not, at the time, know what to do with the not-fitting. I filed her, in the way clinicians file what they cannot account for, as an exception. Over the years, the file of exceptions grew. The pattern in the file is what the rest of this site is now trying to name.

She taught me, finally, to keep my eyes open and to never give up too soon.

9. Thirty years on

Thirty years at the bedside have settled the long opening list of what those years taught into a shorter one. They taught me presence and attention. They taught me to honour the family who has carried me through every year of practice and through every case I could not put down. They taught me that the canonical bio-medical training I had received, valuable as it is, was not the whole picture — and that consciousness is doing something the standard view does not have the architecture to ask about.

Honouring the family was not always easy. It would have been very easy to avoid my family responsibilities by claiming work was too hard today, or I have no energy for that. No way. My family responsibilities, strangely, kept my life in balance by requiring my full presence and attention at home, and prevented me from propagating the negative intensity at times generated by my frustrations at work. My family kept me grounded through the years, and I am very fortunate and thankful for it.

The Mary Parker case became, years later, the seed of the Mary Parker character in Anima — Section IV, The Ones Who Stay. The literary form is not a fictional invention. It is a real clinical case, lightly translated, that has stayed with me for the better part of three decades. The trilogy gives her the room to do, in the form of a novel, the work she did in my practice: she opens a door. The work of the Synthesis and of the companion essays on this site is what has, slowly, been built behind the door once she walked through it.

The door is still open. The patients, in their thousands across the years, keep walking through.

This page is part of the Reading companion essays. For the discipline of presence that the thirty years made possible, see Death and Dying — a physician's notes on presence at the bedside. For the literary form of the same clinical archive, see Anima — Section IV (Mary Parker; Mr. Martinez; the other cases that opened the door). For the empirical literatures the door leads to, see Terminal lucidity, Pre-birth memory and the Stevenson archive, and the receiver-signatures catalogue in Why biology? §4. For the wider synthesis, The Evidence.