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Grand Rounds

Meaningful memories

By Joanna H. Fanos, Ph.D.

There can be any number of factors that influence physicians to choose a career in medicine. But I have found, in my 25 years of research experience, that the decision to enter medicine is often linked to encounters with the world of health care during childhood or adolescence—and that these experiences continue to exert an influence long after medical professionals enter practice.

Some years ago, I interviewed 30 pediatric oncologists, including a number who were among the best and brightest in their field. Strikingly, more than half had experienced a major illness during their own childhood or adolescence. One physician had been severely burned at age three; another had been stricken with polio as a five-year-old. A common theme in their memories of threatening and mystifying childhood illnesses was an image of an individual physician or of a specific treatment that had saved them. Several of the oncologists, for example, were cured of serious bacterial infections by what was at the time a promising new medication: penicillin.

Other physicians endured frightening, even traumatic, experiences connected to their illness. One physician described a terrifying trip to the emergency room following an allergic reaction to aspirin. Several others recalled encounters with medical providers who were either indifferent or unkind. For example, one physician remembered as a five-year-old chatting with an aide on the way to the operating room to have surgery. He proudly told the aide how brave he felt. Instead of being supportive, the aide warned him "to wait and see." Those who had gone through such experiences vowed that no sick child they came across would ever be treated in such a manner.

Fears: The illness or death of family members also loomed large in the memories of these pediatric oncologists. Three-fourths of those I interviewed had witnessed the effects of significant medical events on family members, including the loss of a sister or mother to cancer. One physician discussed becoming anxious following the death of his grandmother when he was nine. His parents were unable to assuage his fears, and he said that he chose oncology "to deal with death." Another physician, who lost his brother to a rare childhood cancer, now works in the same hospital and on the same ward where his brother died years earlier.

The reflections of these pediatric oncologists mirror what I've found while conducting many other interviews with people who grew up in families in which a sibling died from a serious illness. As I've listened to their stories, I've encountered another common theme. Whereas children growing up in a "normal" family typically idealize their parents, children with a seriously ill sibling perceive their parents as helpless in the face of this grave danger. These children tend to idealize a medical provider, and many of them are eventually drawn to medical fields. Here, as with the pediatric oncologists, the choice of specialty generally is not random; instead, it's linked directly to their early encounters.

One example comes from interviews with siblings of children with X-linked severe combined immune deficiency, the genetic disorder commonly referred to as the "bubble boy" disease. I found that these siblings had grown up hearing their mothers extol the virtues of the nurses who had been so helpful during their child's bone marrow transplantation. One-fourth of siblings I interviewed eventually became nurses.

Another example comes from interviews with adults who as children had lost a sibling in the neonatal intensive care unit (NICU) at Dartmouth-Hitchcock. More than a third sought to enter the medical field and several hoped to become neonatologists, including one who as a 16-year-old volunteered in the NICU at DHMC.

Bout: In talking to siblings of children with cystic fibrosis, a life-threatening pulmonary disorder, I found that many had accompanied their families to the pediatric clinic, and a number of them expressed a desire to become pediatricians. The legendary physician Harry Shwachman, a pioneer in the understanding and treatment of cystic fibrosis, offers a case in point. When I spoke with Shwachman about his interest in medicine, he mentioned surviving a life-threatening bout of bilateral pneumonia as a child. He recalled how frightened he was, how his father carried him into the doctor's office, and how kind the doctor was.

Childhood experiences can be a powerful motivating force for medical professionals. These events are also important because they can affect physicians' responses to emotional stress—brought on, for example, by the death of a patient. Dr. Joseph O'Donnell, senior advising dean at DMS, has written eloquently in these pages about the need for all of us—not just medical students—to grow ethically. Part of the challenge of ethical growth is mastering our formative experiences and helping others to do the same.

Embrace: A thoughtful self-awareness can guide medical professionals as they make choices about their career paths. In addition, those of us who teach medical students should help them identify and embrace the personal experiences that influence their medical interests, rather than disavow them as vulnerabilities. We can encourage medical students, interns, residents, and young colleagues to honor their past so that they can fully be present in their encounters with patients. We can set a model of caring for the caregiver.

The Grand Rounds essay covers a topic of interest to the Dartmouth medical faculty. Fanos is a research assistant professor of pediatrics and a member of Dartmouth's Hood Center for Children and Families. She is spending this year as a visiting faculty member at the Stanford Center for Biomedical Ethics in Palo Alto, Calif.

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