Admitting someone to a religion or a community is a very serious business. We live part of the year next to an orthodox monastery. Over the years I have watched the young people who the bishop and the monks agree are worthy to become apprentices, the process saying as much about my friends the monks or the bishop as it does the aspirants. The vetting process for religious orders is ancient, well-known, and, in many cases, steep. I went to a Jesuit high school where the bulk of the teaching was by scholastics who, we were told, if they made it successfully through the next 11 years, could finally gain permanent entrance to the Society of Jesus. Scholastics, or their equivalent in any religion, are watched and measured before they are tapped to move to another level. Becoming part of a community is sometimes a more complicated process, containing many implicit and few explicit guidelines. The old story about the obituary in a Maine newspaper for the man who lived all but the first six months of his life in Maine with the headline "Massachusetts Native Dies at 94" depicts a regionalism that is humorous and equally serious all over this country. My brother's Midwestern accent, even after 25 years in New York City, still signals to people who deal with him that he is probably a pretender and they tolerate his behavior with a nod and a wink. Community is a sense of being home, of belonging, which comes with time and generations. While we may live somewhere for a long time, it is the community itself that decides to let us belong. Who gains entry into the profession of medicine should also be serious business. Over the three decades I have been involved with medical schools, I have served in one capacity or another around admissions for ten of those years. Admissions committees are very interesting places. Members express feelings about values and engage in serious and often contentious arguments based, everyone agrees, on what the arguers believe are the qualities that make good doctors. If one really wants to find out a medical school's character, listen in on its admissions committee discussions. Biology MCAT scores are put up against family background, advanced biochemistry courses against humanities and social sciences, volunteer service against working in someone's lab. How those discussions are resolved is a mystery, even to members on the committee. Personal pleas are made, trade-offs are employed, exhaustion sets in. Sometimes, in frustration, committees fall back on numerical scores as the arbiter—a wholly unsatisfying process. We don't teach numbers. We teach people. Deciding who enters is hard work indeed. For years I was the unofficial essay reader of applicant files on the admissions committee, in part because I enjoy words and because I believe that how one uses words and the stories they tell can reflect on one's ability to care for patients. After all, physicians are always writing, in one form or another, or at least recording versions of the patient's history in charts and letters. Communication in medicine is often, if not exclusively, written, and clarity and thoughtfulness are valued. Ten years ago I noticed that a single phrase—"I have always been fascinated by the human body"—was cropping up more and more in applicant essays. In fact, a fellow reader on the committee and I found it present in almost a quarter of the essays in applicants who made it to the discussion stage of the committee over a three-year period. It got to the point where a committee member reviewing a portfolio would mention that the applicant had "used the phrase," and the entire committee began to wonder what was going on. Our conjecturing about the reasons for the ubiquitousness of the phrase ran from a secret book for premeds that said if you use it, you will get in, to the mechanistic/reductionist view of biology, partly reinforced by the computer-as-human extension. The fascination with the body may come from what 22-year-olds applying to medical school think medical school is—at least the year they can see ahead of them. That first year does have a lot to do with the body: human anatomy is very interesting and has occupied a place in art for centuries. Rembrandt's The Anatomy Lecture of Dr. Nicolaes Tulp is a wonderful painting, full of light and shadow, with the cadaver front and center, reminding us of the physical aspects of death. But the painting is also about the faces of the students, and the instructor, as much about the living people in it as the dead body. But our greatest concern was that "the phrase" may sum up what potential physicians think medicine is really about, and that, perhaps, was the most unsettling explanation of all. The human body is fascinating, I suppose, but in my experience it can also be disgusting, seductive, neglected, or resilient. Teaching physical diagnosis over the years has shown me that many, if not all, preclinical students have a platonic fascination with the body. When it comes to touching and probing, students' fascination seems to retreat behind discomfort or unease at crossing the physical barrier between human beings. In all cases, the body is the vehicle for the person we meet inside it, letting us marvel at the soul that inhabits a damaged person or the lack of one in someone whose physical appearance is perfect. Medicine is the people we meet along the way—pain, worry, or suffering provides the excuse to meet them. The concern I have about "the phrase" is that those who use it, particularly in the positive vein in which it is offered, truly believe that the solution to the problems of the human body, just as it is to many things biomechanical, is to find the right drug, spare part, program, or, increasingly, genes to right what is wrong. What is true about medicine is that human beings, not human bodies, have the ability to dazzle us with their unpredictability. The news is always full of stories about the 110-year-old who chewed tobacco all her life and the marathon runner who died of sudden death at 40. I don't take that as a reason to start handing out tins of snuff to my patients or encouraging them to eliminate exercise. I still follow the odds. But I want to know what it is about some people that lets them beat the odds. I want to know what sustains someone who, by all measures, should be defeated. The "why" of both health and illness is the true fascination in medicine, and it is the person, not his or her body, who holds the answers for us. I want to take the student who is contemplating a career in medicine into the room to meet Ms Smith, who is 85 and has curled downward over the past 15 years, her back misshapen, her weight straining toward but never attaining 100 pounds, and who makes you get down in a crouch or put her up on the examining table so you can make eye contact, her face wrinkled like an apple-core doll. She "aches all over" but not enough to keep her from moving to town to take care of her widowed older sister. Her body is fascinating. She, however, is much more fascinating than her body, and everyone who has ever met her knows her eyes really do twinkle and she has a sense of humor and a chuckle that shines like the sun. I tried to remember what I wrote or said when I applied to medicine school, but truthfully, anything I would tell you would be fiction, lost in the volume of words and stories since. I dare any physician out of medical school to recall with some specificity what he said or what she wrote. Most of us remember the interview and the feeling—dread, despair, elation, relief—that went with it but not what inept things we said. However, who we were—then—seemed to have come through positively enough for the committee to feel that who we might become—now—was worth betting on. It is a very good thing that we are not held accountable for all the things we said or wrote when we were 22. So if "the phrase" still crops up in essays in this century, which it does, I can't hold it against students, other than wanting to remind them of it when they graduate and see if they have changed their "fascination." I hope so. If they haven't, we as their teachers have failed them. The wheels of the admissions process have turned again and produced a set of 145 new names and faces to begin the journey. I know a few used "the phrase" in their applications and still made it in. I am looking forward, however, to reading this year's essays, for the one that contains a phrase I have never seen in all these years: "I have always been fascinated by human beings." Dedication: This article is for Don Madison.
JAMA – American Medical Association
Published: Nov 8, 2000