The following are exact quotes from the first volume of my journal (except for the bracketed words). I was in my second year of residency in internal medicine following a rotating internship. It reflects how many in medical training try to make critical choices, and how important my journals have become to me.
30 August 1962
I begin this record for several reasons. First, as a tool for putting my ideas and thoughts down that I may view them later and judge them with the logic that can only come with remoteness. Second, to practice the art of writing at which I am so woefully weak. Thirdly, as a sounding board that I may speak as harshly or kindly, logically or irrationally as I wish that I may come to know myself better.
1 September 1962
Had a long talk with Dr. Trobaugh [head of hematology] today—he opened the conversation by saying how much he enjoyed having me on the service and he liked my curiosity and industry. He then hinted that he would like to know what plans I had. I told him the mental gymnastics I was going thru trying to decide between practice and an academic career. He said that was a problem, but offered several points:
First, he said it was easy to go from academic medicine to practice, but not the opposite. Second, that internists should have a “gimmick” that they might become very highly specialized in a very small field for both esthetic and practical reasons, and that they might grow with these specialties in the years to follow. Third, that a man need not sacrifice his family or himself for the privilege of doing a fellowship as in years past because there was now adequate recompense for a comfortable living.
He spoke in such a manner about these and other things that reinforced my newly acquired belief that he is an extraordinary man with a great deal of talent, peerless integrity, and a penchant for seeing thru the maze of trivia to extract the heart of any matter. I admire him, and would be privileged to work with him if this ever came to pass.
4 September 1962
Worked all day yesterday at the clinic [moonlighting job at an industrial clinic]. I must admit that I do not like the job, but the money is very good. I think part of my displeasure stems from three main reasons:
First, I don't like the type of medicine practiced there. It is highly empiric, more so than I think a practice can allow for safety. I must admit that my view is perhaps stinted by my hospital training and general lack of experience in practice. But I seriously doubt that I would enjoy practice if it is like that. I require more satisfaction (and I do not equate this with success). I am sure I would have many questions that I couldn't have answers for, but the opportunity for seeking those answers isn't there. Maybe this is the tip-off that I should be in academic medicine.
Secondly, I don't like working for someone on his terms exclusively. There are a very high percentage of people I see [at the clinic] at odd hours and on Sunday and holidays who need not be. If it were my practice, I'm sure I would accept only emergencies at those times. Of course, Dr. D's chief motive for offering 24-hour service is to funnel more surgery to him—he just completed four years of general surgery residency after having been in practice many years. I admire him for the latter.
Thirdly, and this is disturbingly fundamental, I have difficulty in taking money from people for medical services I render. I know all the arguments about just pay, etc., but perhaps I am still too idealistic. However, in my present frame of mind, and after much personal thought and debate, I wonder if a physician shouldn't be guaranteed a good basic salary and practice without regard to finances. I know this is socialized medicine, but I think it may be a point in its favor. In my own personal experience, though small, I have already seen how my decisions and judgment can be swayed by the financial questions. I would very much like to see a discussion by recognized authorities on the standards and justification of physicians' salaries—how they are set or come about, what yardstick should be used, etc.
8 September 1962
Had a brief talk with George Flanagan [a young staff physician] today. I casually raised the point about my enigma—what to do after my residency—and he raised some very good points. He again states that my first decision is one that no one can help me with—i.e., whether I want an academic career for the rest of my life or if I would sometime like to practice. This will make any subsequent decisions much easier.
He himself spent a year at the Cleveland Clinic in endocrinology and it has done him a world of good. If I decided that I wanted to eventually practice but wanted extra training (so called “gimmick”—I hate that term), I could take a clinical fellowship for one or two years. However, if I strongly consider academic medicine, then I must take a fellowship involving some very basic and fundamental research.
About the latter—I have some serious doubts about my ability to cope with basic research. All those I have seen in basic research have been exceptionally brilliant people.
Another problem is that in spite of the aggravation and ulcerogenic effects of clinical medicine, I still like it very much. Fundamentally the only reason I have any hesitation about just going in to practice is that I don't think it will be enough—I need something more, something I can “live and grow with,” to quote Dr. Trobaugh. So, I have definitely decided on a fellowship of some kind, but I must narrow it down and become more specific before I can talk to Dr. Campbell [chair of medicine] about it.
Human nature being what it is, I can see many examples about me of physicians who have become academically and scientifically stagnant. It is so easy. Some form of inspiration or prodding or fear is necessary to keep us working at our best. I think the fellowship would give some momentum to me to keep me out of the quagmire.
OK, back to 2015. Starting the journals was an important gift to myself and it worked very well for me, just as I had hoped. It reminds me that I was idealistic, that my handwriting was 100% better than that it is now, and that the logic I used thinking about my future still rings mostly in line with my current views, which surprises me somewhat.
In my old age filled with experience, I am often called upon to give career advice to medical colleagues and acquaintances, just as others helped me think of my future. My journal is up to 33 volumes now and I still make entries every week or so when I have something to get off my chest or to help me clarify an issue.
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