Choosing a Specialty: A Letter to a Medical Student

Nassir Ghaemi, MD, MPH


January 04, 2017

Part 3

By the time you've mastered your profession and completed your lifelong education, you may find that your time has run out. So said the depressed Henry Adams. Maybe it's not as bad as he thought, but he had an insight.

That's how it all looks at middle age, but the optimism of youth has a twin in the optimism of old age, because once you get into the latter years of your career, you'll find that some of your younger colleagues will value you more. Your old enemies will have withered away, and the world will listen to what you have to say. You won't be able to storm the barricades yourself, but you'll direct the younger ones on where to go and what to do. The only final blow: You won't be there to see the victory. Like Moses, you may not make it to the Promised Land; only Joshua will.

This is what change in psychiatry feels like. It's glacially slow, if it happens at all.

All these comments are based on one assumption—that the past predicts the future, that the next 20 years will be like the last 20, and the next 50 years will be like the last 50. I think this is a fair assumption, because human nature doesn't change. But it is possible that other social or economic factors may drive changes in the psychiatric profession that are unpredictable. It may be that smartphones and new technology will speed up change, promoting new ways of thinking and an end to the old. But maybe not.

So there is psychiatry for you, riddled with ideologies for two centuries, stultified by the conservative instincts of human nature. People prefer the status quo to change. Our ideals are mouthed and empty. We don't really want scientific progress, or to discover the causes of mental illnesses, much less cure them. What we really want is for things to stay the same.

I realize that these criticisms apply outside of psychiatry; I'm sure they apply in obstetrics to some extent, and in cardiology, and in dermatology as well. I know they apply in other professions, and in society at large, certainly in our political life. Some will say that all professions are corrupt; this may be correct. I'm not singling out psychiatry as uniquely different in this regard, but there is a matter of more and less. Psychiatry is plagued deeply by its self-deception.

To put it another way, relevant to all professions and all of life, but especially to psychiatry:

It's an unjust world. How will you live in it?

You have three options. The first is passive acquiescence; this is what a normal, mentally healthy person does. Most of us conform to the world as we find it. Go along to get along. Join the mainstream. Accept the status quo. Kiss up, kick down. This is normal, because conformism is the virtue most rewarded by society. The world will leave you alone at worst, and applaud you at best. But you'll leave it as unjust as you found it.

The second option is violent resistance; by "violent," I don't mean just physical acts, but verbal and mental ones. You resist the world's unfairness, but you are angry and bitter. You defend the weak by hurting the strong, but you create enemies all around. You may do some good, but you'll die by the sword, and after you, your enemies' children will fight your children.

The third approach is nonviolent resistance; by "nonviolent," I mean that you fight your enemies, but you don't hate them. You're not angry, you're a "happy warrior;" you seek not to defeat, but to persuade; and if you can't persuade, to simply stop evil without harming the evildoer. You may not persuade your enemies, but their children and grandchildren will come around to your view. You'll leave the world a better place.

If you seek to take the hard road, I advise you to be careful, and learn the methods of nonviolent resistance. Study Martin Luther King and Mahatma Gandhi, not because their lives were happy (they weren't), but because they left a legacy of progress which millennia of history failed to provide. It's the same in the profession as in larger society: We've been fighting each other for centuries, without meaningful progress, because we've either been violent in mind and word, or we've been passively acquiescent. The third road is the hardest for the person, but the best for the world.

As for you, look into your soul. Don't be shy. Be honest. Be brutal.

I have thought that Nietzsche got it right: One way of understanding these matters is think of our task in life as becoming who we are. You are someone; it may take your life for that someone to unfold. You do well to become who you are, rather than to deny yourself, or distort yourself, or never to get to know yourself. You don't really know who you are right now, but you have an inkling. And over time, that inkling can grow until you are more and more confident in yourself.

Freud had another insight into it. He said that in decisions of great importance—such as choosing a career, or whom to marry—he found that it was best to go with one's inner instinct, with a sense of what's right that might be difficult to explain or defend. This intuitive approach is more accurate, he thought, than purely rational calculations, because it puts you in touch with your deepest needs. So as you look into your soul, pay closest attention to your intuitive feelings, even if you can't explain them.

It isn't a fault to want to live a quiet life. You don't need to be a hero. If you want to make a living, make a living in that field which will provide you the least daily hassle. Then follow your dreams outside of your profession. Make a living however you find most profitable, but find the passion of life elsewhere. Look into what gives you meaning, what you think will give your life its deepest meaning. Put your efforts there.

If you feel a deeper calling within the profession, follow it, but prepare yourself for the resistance of the world. Find your solace inside yourself, not outside. And know then that you are like the saints of old, but in a different era, doing God's work in a world where gods no longer are recognized.


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