An excerpt from This Won’t Hurt A Bit (and other white lies): My Education in Medicine and Motherhood. Copyright © 2011 by Michelle Au. Published by Grand Central Publishing.

Let’s look at this first purely from the perspective of personal investment and expectation. To practice medicine, first, you have to go to medical school. That’s four years right there. Then, there’s residency, which adds anywhere between three and seven years to the deal. After that, there may be a fellowship, sometimes two fellowships, because really, at that point, what’s another year or two (or six)? So basically, from the moment you start into medical school to the moment you finish your training, you’re looking at a minimum of seven years—for most people it’s closer to ten—before you’re even close to being considered a “real” doctor.

And these are not fun, carefree years—certainly not the way most people spend their twenties, at least if the producers of MTV or beer advertisers are to be believed. You spend these fetal-doctor years indoors under fluorescent lighting, nose pressed into books filled with inscrutable diagrams and endless acronyms, while everyone in the world, including some of your patients, appears to be having more fun than you. These are years spent doing a whole lot of work for little or no money, ignominious tasks relegated to those contractually obligated to never complain. These are years of thousands of lost hours spent at the hospital instead of with your friends and family, who always seem to be wondering where you are and why you’re still there and when, if ever, you’ll be coming home. These are years spent defying all common sense about circadian rhythms and the regenerative powers of rest, largely awake and caffeinated to an almost toxic degree. And—this last part is the real kicker—these are years after which you will end up in hundreds and thousands of dollars of debt, all for the experience of what amounts to hard time in a well-intentioned Soviet gulag. I repeat: not fun.

It was true that I wanted to be a doctor, but there were other things I wanted to be at the same time. Like many people I knew, I imagined that by the time I was thirty (OK, maybe thirty-five), I would be in a committed relationship with someone that I loved, or at least sort of liked. Maybe I would be married. Perhaps I would have kids, presented the time and the opportunity and provided that the corrosive powers of time did not rob me completely of my reproductive potential by the time I was ready for the responsibility. Barring that, maybe I would have a dog. Or at least a fish.

But then I would go into the hospital on my General Surgery rotation and see a bunch of bitter, tired men in their thirties, still years away from their first paying job, all either single or divorced or in some way separated from their spouses, and their sole message of wisdom to impart to their medical students was, Dude, whatever you decide to do with your life, don’t do this.

But despite it all, despite the complete disconnect between the life of medicine as we saw it and the real life we envisioned for ourselves, many of us decided to become doctors anyway. Why? I believe that for most people, there’s a spectrum of reasons.

First and hopefully underlying all the other reasons, there’s probably the pure and honest desire to want to do good in life. I want to help people. Put aside the fact that many jobs are expressly designed to help people—the barista helps people by getting them their coffee, the dry cleaner helps people by pressing their shirts, the street mime helps people by making them realize that no matter how terrible they think their lives are, at least they’re not street mimes—and you have what seems like a pretty good blanket answer to throw out there at interviews and family functions, provided that there are absolutely no follow-up questions. (Unfortunately, there always are.)

Perhaps some people have a special facility for applied science. That seems reasonable enough. There’s so much Biology and Chemistry and Physics and Physiology in medicine that in medical school, we spend two straight years studying nothing else. That said, there are plenty of people who are gifted in Biology and Chemistry and Physics who have no business being anywhere near other human beings, and would perhaps better serve the world in the back of a computer lab, writing Battlestar Galactica fan fiction and engaging in heated online arguments with others doing the same.

Maybe you have had a Medical Experience, and as a result of your Medical Experience you had an epiphany and decided that you would like to become a doctor yourself. A personal incident of illness or injury, time spent caring for a sick parent, a particularly moving episode of ER circa The Clooney Years—this overall seems like a valid precursor to a career in medicine. (Well, maybe not the ER thing.) You have had an encounter in the field and have some true and earnest desire to either perpetuate the good that you have witnessed or to expose and eradicate the wrongs. However, if this were the main reason that people decided to become doctors, medical schools would be filled with classes of students with dead parents and crippled siblings, and at least from my experience, this is not overwhelmingly the case.

There are, however, plenty of people in medical school who have a doctor in the family. Usually one parent, sometimes both. Coming from a medical dynasty can have its pluses and minuses—on one hand, these people are usually down-to-earth and diligent, as they are going into the family business and know both what to expect and what is expected of them. On the other hand, some of them act like by virtue of birthright, they are doctors already, and the actual process of medical training is just an unfortunate technicality.

Sometimes people become doctors because it’s a well-respected field with which most people have a passing familiarity. The window dressings of medi•cine are well known to any layman with a television—the long white coats, the stethoscopes slung casually around the neck in battle-ready position, the Hippocratic oath to “first, do no harm.”

The doctor is an icon, instantly recognizable. Children tell parents they want to become doctors the same way they say they want to be teachers or scientists or astronauts, because they know what doctors are, and what they do, and because expressing an interest in medicine makes parents instantly happy. (Maybe there are some children who express the desire to be hedge fund managers when they grow up, but those children should probably be checked periodically for clustered sixes in the hairline.) Early on in medical school, some guys in my class used to go out to bars wearing their medical school IDs with the notion that it would help them pick up women. While their technique was dubious, they perhaps more than any of us understood the power and respect of the medical degree. And the thrill that a new intern feels the first time she is referred to as “Doctor” is universal and undeniable, the excitement of finally being accepted into an exclusive pantheon, something like being knighted.

And let’s not beat around the bush, sometimes people decide to become doctors because of the money. No one talks about it, but risking excommunication, I’m telling you. It’s hardly a “get rich quick” scheme, but for most of us, it is at least a “get moderately well-off slow” scheme. While I certainly don’t think that you should go into medicine solely for the money (there are much easier ways to earn money—growing and selling your hair for high-end wigs comes to mind), I also don’t think it’s wrong to consider a career in medicine for its practical benefits. A stable career with good earning potential—isn’t that what most people look for? But no, we don’t speak of such earthly concerns, especially not when the popular notion of The Good Doctor imagines him subsisting solely on handshakes and goodwill. Though no one ever seems to want to talk about the details, I can confidently tell you that while income varies across specialties and geography, overall, doctors make a lot of money.

So there is altruism. There is the academic interest. There are societal influences and personal influences and there is of course the matter of money. Students going into medicine probably cycle through most if not all of these reasons at some point in their decision process, sometimes multiple times in one day. It is easier, for example, to be altruistic at 9:00 a.m. than at 2:00 a.m. Motivations also may change as an individual matures, and the rosy idealism of the twenty-two-year-old first-year med student may eventually give way to the real-world considerations of a married father of two trying to support a young family on a single salary. I can’t understand everyone’s reasons or the factors that temper their decisions, but in most cases it boils down to this: we want to become good doctors because we want to be able to make a positive and meaningful difference in the lives of people when they need help the most. And for this privilege, we’re willing to deal with the rest of it.

But I will tell you one thing I know for certain. No one decides that they want to be a doctor because they want to be a scutmonkey.

So what, the civilians want to know, is a scutmonkey?

There are versions of scutmonkeys in most professions. The entertainment business has its production assistants, the mob has its “button men,” and in medicine, we have our scutmonkeys—the hungry, scrabbling masses charged to do the jobs no one else wants. Sometimes these jobs are distasteful, almost always these jobs are menial, and not infrequently, these jobs are just flat-out boring, which is probably why SCUT is perhaps best understood as an acronym one of my residents passed on to me: “Sub-Cerebral Use of Time.” And yet all of us in medicine, from the silver-haired senior attending on down, have at one time or another been scutmonkeys.

Luckily, being a scutmonkey is a temporary condition. It starts with medical school under the guise of education, fully manifests during residency and fellowship, when we are technically paid to get scutted out (and why senior doctors feel free to assign scutwork with much less guilt), and resolves itself fully upon completion of training. Despite the painful and often protracted nature of the scutmonkey years, senior doctors often seem to have a degree of retrograde amnesia when it comes to the travails it took to get them there. Sure, they have their stock of old war stories, which are pulled out, dusted off, and, like baby pictures, passed around the assembled audience, where they are duly admired or subversively one-upped. But overall, doctors finished with their training see themselves plucked from the mire and deposited into an altogether more agreeable lifestyle, not unlike Willis and Arnold on Diff’rent Strokes, though perhaps with even less interest in looking back. And really, it doesn’t take long to forget the old neighborhood. “Honestly, things are completely different now,” one young attending once told me. “It’s so much better. You just wait and see. I can hardly remember what it was like to be a resident anymore. I honestly can’t believe I used to live like that.” She had graduated from her Pediatrics residency all of six months earlier.

Nobody goes into medicine to be a scutmonkey, but almost all of us look forward to what comes after. The day when, we envision, we will be able to practice medicine the way we want. The day when we will be able to decide what and when and how things will be done for our own patients during the day, and yet have enough freedom to have lives outside of the hospital as well. When we will be valued for our years of advanced education, for our clinical expertise, for our judgment, not just for the decerebrate ability to write down lab values and page EKG technicians and push stretchers from Point A to Point B at 3:00 a.m. The day when we will have scores of little scutmonkeys of our own to dispatch on a whim, to take care of the things that we will be too important to do.

Michelle Au is an anesthesiologist and author of This Won’t Hurt A Bit (and other white lies): My Education in Medicine and Motherhood.

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