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Article

Oncology Fellows
September 2018

Emerging Adulthood: From Adolescent to Attending Physician

Faced with a persistent question from her teenage years, Elaine Chang, MD, may have come up with an answer.

Eliane Chang, MD

What do you want to be when you grow up? It was a common question to be asked as children, as soon as we learned the meaning of the words “job” and “work.” By the time I graduate from high school, I am answering earnestly, “I want to be a doctor.” I am blissfully unaware that no one at age 18 has any inkling of what that means. And so emerging adulthood begins, as described by Jeffrey Arnett in 2000, pertaining to young adults between 18 and 25 years of age who do not have children, do not live in their own home, or do not have sufficient income to become fully independent.¹ It is the period of time when adolescents become adults by exploring the seemingly endless possibilities of life directions.

What do you want to be when you grow up? In college, my understanding of this mysterious guild guarded by the Hippocratic Oath does not grow much. I know that I want to help people, change the world, and have enough money for a comfortable lifestyle. Medicine still seems like a great career to accomplish those goals.

What do you want to be when you grow up? In medical school, I still want to help people and change the world; but in the meantime, I need to study, study, study; then choose a residency; and then match. I keep my head in the books because fear of failure is always crouching at the door. Selfishly studying sucks out the sense of personal achievement and feeds professional burnout, especially when nostalgia for the college days, when I used to help people in tangible ways, hits. I console myself and strengthen the delayed gratification muscle: “It’s just temporary. Study now, so you can be a better doctor and help people more effectively in the future.” Even after I start rotating wards and studying is no longer occupying the majority of my days, I’m at the bottom of the totem pole and not sure how to navigate my role. Confidence and the sense of personal achievement are at all-time lows. By the time I graduate with my medical degree, I begin to wonder, “When am I ever going to graduate from emerging adulthood and reach adulthood?”

What do you want to be when you grow up? I want to help people, and as an intern, I finally can. Those moments, I think “I’ve finally arrived.” My new goal is to be a competent physician. Being a consistently excellent physician seems like an unrealistic goal on most days. I’m just trying to survive, like Cosette sweeping the floor, singing “Castle on a Cloud.

The only way to stay afloat is to figure out what my superiors want of me. But I start learning to tell stories, narratives that illuminate different perspectives of familiar situations faced by the medical trainees; that acknowledge and interpret the challenges common in our interactions with our colleagues, patients, and society; that absorb and interpret experiences in a way that shapes our character and how we see our role in the world.3-7 Stories become a modality for discernment: “Of all the things I do, which things matter? Which threads do I want to keep and weave into the narrative of my life? How do these threads give me hope for a meaningful future?”

What do you want to be when you grow up? Having miraculously survived internship, I am now a resident applying for hematology-oncology fellowship, after meeting several admirable attendings and thinking to myself, “They are great people. I want to be that efficient and effective, influence medical students and residents, practice fantastic communication skills, and show compassion to patients and colleagues.” By now, I’ve been in a rigorous academic environment for 20 years. The atoms of academic curiosity make up the air I breathe and are embedded in every cell of my soul, becoming the framework for an academic career.

What do you want to be when you grow up? Fellowship is like intern year all over again—in other words, survival mode. Two years pass, I’m in 26th grade, and oops, I realize the feeling that I’m Cosette hasn’t left me, that I’m sweeping the floor, but I am increasingly urged to straddle 2 worlds, as well-intentioned superiors admonish me, “Start building your castle now. How many floors? How many staircases? What color walls?” as the adult questions percolate in a befuddled puddle in my mind. Do I want to join a group private practice and have a comfortable lifestyle, with time to be a human being outside of medicine, but stoop to conniving business relationships and grovel for referrals? Do I want to stay in academics, preserving my naïve, idealistic self who doesn’t have to plot shrewd business moves, but remain under the mercy of institution politics? Do I want to spend my days being creative, asking questions and designing research studies to answer them, but under the gun of submitting grants every 6 weeks? And then there’s industry—I don’t know much about that aspect of the medical world, but I’m pretty sure I don’t want to travel that much.

I begin to realize that we have stereotypes of all these careers, and we’re expected to apply for jobs based on these skewed stereotypes. Additionally, we are trained to be perfectionists and excel at everything—teaching, clinical acumen, communication, research—just like Cosette is certainly trained to sweep, wash dishes, do laundry, scrub the floors, and more.

Does it come down to “just do/pick something?” Maybe there is no wrong choice. My theory is that many of us make decisions based on the stereotypes of these careers and the stories we tell about ourselves. We develop an identity as an altruistic person, and the only way we can be in underserved care is to stay in academia. Or we develop an identity as an altruistic person, but we have too much debt, so we need to go into private practice, and we tell ourselves we’ll make up for it in the future by donating to worthy causes. Or we develop an identity as a smart person who thrives during tumor board discussions, and we get on the academic clinician-educator track. Or we develop an identity as a smart person who wants to leave a mark forever on medical history, and we jump on the academic physician-scientist track.

Maybe we need to start telling more nuanced stories about ourselves and these careers. We need altruistic, pragmatic people in industry, committed to the delivery of effective drugs to people in need. We need creative clinicians in communities everywhere, willing to use their brains in applying evidence-based medicine to each patient individually, rather than universally or blindly following heuristic techniques. We need business-minded entrepreneurs in global health who can negotiate, forecast, and lead within cost-effective, sustainable growth models.

Many of us may feel like we don’t have stories to tell. Where do we find the setting, the characters, and the storyline? We need to reach down into our memories, search for, and reflect upon:

  • The people with whom we enjoyed working with or the patients we have enjoyed helping
  • Our favorite transferable skills
  • The working conditions that enabled us to work at our top form and effectiveness

The organizations most in line with our mission or purpose in life As Andrew Delbanco8 writes in The Real American Dream: A Meditation on Hope:

At the heart of any cohesive culture is a story that gives it hope, a story that helps us overcome the lurking suspicion that all our working and getting and spending amounts to nothing more than fidgeting while we wait for death. Hope depends on finding some end to be pursued more extensive than merely instant desire…Without it, we are, as the anthropologist Clifford Geertz has put it, “a kind of formless monster with neither sense of direction or power of self-control and a chaos of vague emotions.”

References

  1. Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469-480. doi: 10.1089/jpm.2011.0458.
  2. Hugo V. Les Misérables. 2nd ed. New York, NY: Signet Classics; 1987.
  3. Chang E. Refilling empathy. J Palliat Med. 2012;15(5): 615-616. doi: 1089/jpm.2011.0458.
  4. Chang E. The paradox of professionalism. Acad Med. 2013;88(8):1128. doi: 10.1097/ACM.0b013e31829a6855.
  5. Campbell SR, Chang E, Shah CJ. A spoonful of insight makes the medicine go down. J Palliat Med. 2014;17(5):621-622. doi: 10.1089/jpm.2013.0443.
  6. Campbell SR, Chang E. Memoirs of an ACGME resident member. J Grad Med Educ. 2014;6(3):595-596. doi: 10.4300/JGME-D-14-00260.1.
  7. Pemmaraju N, Chang E. Healing words. CMAJ. 2015;187(5):360-361.
  8. Delbanco A. The Real American Dream: A Meditation on Hope. Cambridge, MA: Harvard University Press, 2000.
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