Is there a doctor on board? Not always.

Is there a doctor on board? Since the beginning of my medical training, I have developed a new anxiety over flying. As an intern, the “MD” had been tagged to my name while my medical knowledge, skills, and confidence lagged behind. Now, at the end of residency, those factors have caught up. Yet my anxiety, while abated, lingers. It remains because, deep down my gut reaction to that question is still “no.”

The question assumes that a doctor remains at all times a doctor — not only when taking care of patients in the hospital, but while at the gym, at the store, at a restaurant. This encroachment of professional identity into personal identity breeds disquiet in myself. As the boundaries between doctor me and non-doctor me blur, the entire picture goes out of focus. When forced to acknowledge my physician identity outside the hospital, I find myself adjusting the aperture. Who do I see? Who am I supposed to be? How is the person who was covered in blood and vomit during his ER shift earlier today related to the guy trying to relax with this tiny bottle of airplane wine?

Part of my struggle has been described in the literature as one of professional identity formation. Professional identity formation, as defined by Holden, is “the transformative journey through which one integrates the knowledge, skills, values, and behaviors of a competent, humanistic physician with one’s own unique identity and core values.” This definition acknowledges an important point — this is an issue not just of building the professional self but of integrating that process into the rest of one’s development as a person. Frost discusses how this is complicated by the competing discourses of diversity versus standardization. Before we enter training, we are told that what makes us unique is important. Once inside, we begin a process of standardization, encouraged to become like our superiors and our peers, representatives of our profession on a unified front. This makes me uncomfortable.

I do not mean to suggest that I do not like being a doctor. I like what I do. I enjoy taking care of patients, I love hearing their stories, and I am humbled by my brief cameo in the drama of their lives. Given how much time I spend practicing medicine, it is unavoidable that it would become part of who I am. But, to me, medicine is not a calling. It is a job I love, a job I want to be great at, but it is a job. In a recent study exploring medical students’ views of career calling, it was found that only 54.8 percent of respondents reported that having “a calling to a particular kind of work” was totally or mostly true for them, with 24.9 percent saying this was not at all or only mildly true. These data suggest I am not alone. Like me, many in this large minority may struggle to reconcile the absence of feeling called with expectations of the profession.

Having a sense of higher purpose may help providers cope with the difficult demands of medicine. Part of my discomfort with being a doctor comes from my fear that I might be employing unhealthy, unsustainable ways of coping with pain. Humor and intellectualization are my favorite defense mechanisms. These are what get me through my shift, tools that curiously allow me to retain some of my humanity while threatening it at the same time. For the more tectonic issues that threaten my sense of self, I have been known to employ denial. I wonder whether I am in denial that this job is shaping me into a worse version of myself. What happens to the soul when it is constantly assaulted by the barrage of suffering and social injustice that rains down on us daily? Does it deepen our humanity, making us stronger and more compassionate, or does it leave us disheartened, disgruntled, and demoralized? To the outsider, my jokes may seem cruel. What if they knew that the alternative was crying alone at night? I’ve done that, and I don’t like doing that.

The social constructivist approach to identity formation views individuals as active agents in building their “selves.” Frost identifies three main approaches to identity construction that any trainee employs when entering a profession: standard, alternative and hybrid. He acknowledges that the formation of a standard identity often results in trainees “downplaying or suppressing facets of themselves that do not seem compatible with their evolving professional identity.” Early in my training, I did this. It proved to be ego dystonic and unsettling. I remember one resident in particular who served as a warning. Looking in her eyes, I could tell there used to be a person in there, but she wasn’t there anymore. Standardization stifled and starved all her other identities, until the only one remaining was the one nurtured by the stale coffee and fluorescent lights of the hospital wards. I remember thinking, I can’t let that happen to me.

I, therefore, flirted with the formation of an alternative identity, rejecting all norms of conservative medical culture, but this felt equally unsustainable. So, I have landed on the hybrid, selecting the bits that resonate, or at least avoid dissonance. Like making egg soup, I have slowly added a little bit of myself into the pot over the years, gently stirring, to avoid curdling. I introduce myself as “Gabe” rather than “Dr. Heiderich,” and I do not wear a white coat. This prop, designed to look clean while harboring invisible bacteria, feels like a lie. Rejecting the standard label and costume to a certain extent, I stick to scrubs only. This is safer and more comfortable, both physically and psychologically. And I have kept my long hair. Mostly because I like it that way, but partly as a silent act of rebellion against narrow views of medical professionalism and as a reminder that I can be myself inside a hospital. With a costume that fits, I turn to the script.

Early in training, we are taught a general script that we are supposed to apply to each patient interaction. This script has its own particular language. I grew up speaking Portuguese at home. While I am fluent, most of my social and academic life has been conducted in English. I have found that one’s personality is slightly different depending on the language spoken. For example, while one may be gregarious in their primary language, they may be more reserved in the language they are less facile with. It is therefore inevitable that when I speak the language of medicine my personality also shifts. When I have a difficult interaction with a patient, I find myself thinking how it could have gone differently if I were playing a different role, outside the hospital, using different words. If only I could give them advice or break bad news over a beer. If only they could see the real me.

Focused on playing your part, it is easy to forget that there are other actors equally uncomfortable in their new roles. Thrust into the sick role, the patient is stripped of his or her out-of-hospital identity more jarringly than I am. I put on scrubs in the privacy of my bedroom, and mentally prepare myself for my shift on the ride in. They are handed their costume in public — a gown revealing their naked back — and told to change immediately behind a curtain. I have a script, while they do not. So we end up in a catawampus comedy sketch in which they have to improvise in one language while I follow my lines in another. For the first couple years I rehearsed this play, I was so focused on playing my part right that by the time I had my finger up the patient’s butt I had already forgotten their name. But I’m improving.

Employing the hybrid approach to professional identity formation has given me greater satisfaction with my patient interactions. I have continuously adjusted my language and behavior, trying to find the sweet spot where I can be the doctor and be me. What was once a deliberate calibration has now become natural. This has made me better. Better at connecting with patients, better at providing medical care, and better at answering questions at parties.

Now, at the end of residency, I am relieved. I think I did it. I think I survived with my soul intact. By constantly engaging in self-reflection with the help of my friends, family, and patients, I have managed to retain the majority of my non-doctor self. While the doctor slice in the pie-chart of me has grown, the other slices have not gotten as small as I feared. Instead, I think maybe the pie is getting a little bigger.

Reflection, mindfulness, and guided self-examination have been identified as useful tools in the process of professional identity formation. These tools must be taught, so that struggling trainees can learn to reconcile what they’re bringing into the game with its rules and regulations. Like me, many providers hold their identities in different hands, forever juggling. The goal is not to end this, but to find easier ways of keeping the balls in the air, and healthier ways of coping when a ball gets dropped.

Is there a doctor on board?

If I ever do hear those words paged overhead, I don’t think they’ll trigger as much angst as they once may have. The short answer is, of course, yes. But I haven’t quite figured it out yet. How much time do you have?

Gabe Heiderich is an emergency medicine resident.

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