Can the decision to become a physician ever be a truly rational choice? According to philosopher L A Paul, the answer is more complicated than it may seem. In her book Transformative Experience, Paul argues that when we make consequential decisions, we are limited by our inability to know what that experience will be like in advance. For Paul, a transformative experience is one that has this characteristic and is also likely to radically reshape our future point of view. The decision to undergo a transformative experience amounts to a philosopher's dilemma, because the person choosing the experience and the person who will emerge on the other side of it are not one and the same.
Mikhail Bulgakov's collection of short stories A Young Doctor's Notebook (1925) captures a transformative experience by chronicling the transition of 24-year-old Dr Vladimir Bomgard to independent practice. Newly appointed as the sole physician for a remote, rural hospital in Russia, in 1917, Bomgard records his insights in a journal. For Bomgard, the shock of becoming a practising doctor becomes evident in his first week of work, when he has to do emergency surgery alone. “Forty-eight days ago I graduated from the faculty with distinction”, he reflects, “But a distinction is one thing, and a hernia is quite another.” Imagining what it's like to be a doctor, he discovers, is nothing like actually being one in practice. Even in our 21st-century system of medical training, this epistemic gap remains. The experience of being the medical student holding a retractor cannot be extrapolated to that of the intern or the chief resident. As Paul points out, “until you've experienced it, you can't know what it's like”.
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This epistemic gap can often lead to profound self-doubt. Informed by his own medical training, Bulgakov realistically portrays this uncertainty. When Bomgard picks up the scalpel to perform his first cricothyrotomy, he is overcome by fear. Even after he completes a successful operation and receives praise from a nurse for his brilliance, Bomgard's reaction is one of disbelief: ”I thought she was making fun of me”. Today we would recognise this as a bout of so-called imposter syndrome. With time, the process of being repeatedly “thrown into the deep end” hardens Bomgard's resolve, completing his transformative change. This metamorphosis only becomes apparent when he re-encounters the same pages of surgical text that he had once consulted as a trainee. He now views them in a “completely different light; [as] all of the formerly obscure bits became completely comprehensible”.
In medicine, such experiences can continue to occur beyond training. Most notably, the early stages of the COVID-19 pandemic were a transformative experience for many subspecialty physicians who found themselves suddenly redeployed to intensive care settings. One of us (AL) is a haematologist–oncologist who volunteered to work in the intensive care unit at the height of the pandemic in New York City. Returning to a setting last encountered in residency marked an abrupt plunge into the deep end. Reacquaintance with the details of ventilator modes paralleled Bomgard's last-minute preparation for his first emergency surgery. Although on-demand video lectures have replaced Bomgard's medical library, the challenge of diving into the complexity of acute medical care, and the resultant imposter syndrome, were no less jarring. Overnight, a small window had opened into “what it's like” to be an intensivist. Thankfully, expert subspecialty consultation was available, as many redeployed colleagues shared the same predicament. The complexity and novelty of COVID-19 were only one part of the puzzle. Other challenges included the scarcity of clinical data, thinly stretched physical and human resources, and the absence of family members in hospitals.
The reality of such experiences is that we never know how they will reshape us until we are on the other side. This rings particularly true as we start 2021. Although COVID-19 vaccines and our accumulated experience of managing this disease provide cause for optimism, the emergence of new variants of SARS-CoV-2 and increases in COVID-19 deaths in many countries remind us that much uncertainty about the future remains. Finding ourselves in the midst of a shared transformative experience, there is ultimately a comfort in knowing that the process—and the self-doubt—is shared by many colleagues. For the moment, all we can do is plunge in and support one another as we keep moving forwards.