Champion of the Subclinical?

Ask any pre-med why they want to be a doctor, and they hate you. If you ask a pre-med whether that's true and he denies it, he is lying. EVERYONE hates that question. Why? The med school admissions process conditions it. It's the most obvious question in the world that, through one's application/interview process, one is forbidden to answer honestly. One is forbidden to say all sorts of basic, common, wonderful things: "I want to help people," "I want to care for sick people," "I want to make a difference." All of that is perceived by admissions committees as bullshit and, if you say it, you get shot down from accomplishing your dreams. Instead, you get creative. You talk about intellectual challenges, opportunities to tap into unmet needs, to embrace psychosocial challenges, etc. You're not bullshitting at all, even though it sounds like you are. And you hate that you're forced to sound more fake than your real answer. Once you get accepted, you can technically start admitting that you want to help people... except the problem is that your old answers, your new answers, your answers in between -- somehow they're not good enough. This is real now. Why, really, are you here?

I've decided to start being more honest with myself about the "WHY" of what I want to do with my life. It's the "why" that keeps people on a stationary bike for hours, as it should be in life. That's what I tell people at least.

Lots of smart people in my life have told me that the way to really make an effective impact on the world is to carve out a niche -- a niche that many define as something unique and interesting, specifically that few people are doing. I conceptualize a niche slightly differently: that is, it has nothing to do with whether there are 4 million people doing it or 4 -- so long as it is something meaningful and compelling to YOU, that YOU are uniquely qualified to do in the unique way YOU are going to do it. I'd argue that marketing power is often a function of the enthusiasm and charm one exudes, regardless of how many other people are doing it.

I decided this week that my niche is not the idealistic "I want to help really really really really sick people" that might come out in a pre-med personal statement. I've been giving a lot of thought to the notion that my role in this world may very well NOT be to help really, really, really sick people. Rather, it may very well be to guide and empower the person who is living juuuuuuust under the radar -- functional but limited by SOME aspect of their health-- to enhance their lives. Not only preventing illness but truly optimizing their non-ill state. People pay a lot of lip service to the merits of the big "p" word (PREVENTION... oooooh) and yet, nobody talks much about the difference between prevention and optimization.

At the clinic, my preceptor always encourages his colleagues to alert me when something "cool" happens. Do I want to see erythema multiforme? Zoster lesions? Yeah, it's all cool. But the visits I attended yesterday, where I felt most comfortable, inspired, and genuinely well-suited to contribute were the everyday, run-of-the-mill physicals and vague complaints that are largely dismissed just because labs eliminate physician concern for anything DRASTIC --but do nothing to assuage the concerns of the actual people afflicted by them. And, yes, I will use the word "afflicted" -- because to a given person, that's how it feels.

Truth be told, of all the amazing things to which I was exposed yesterday (including another house call -- where I got tearful watching my preceptor hold the hand of his dying patient), the only thing I feel compelled to write about now is how "at home" I felt to be training on the optimization front.

I am not JUST talking about making the healthy healthier. That's not it. I'm talking about the subtle everyday details of everyday life that compromise health -- actual consequences, referred to as "sub-clinical" yet are hugely important to the person experiencing them. Micronutrient management. Lifestyle management. Breathing control and mindfulness. Proactivity. Hell, I even got to have a conversation about HEART RATE TRAINING with someone yesterday -- and it was the best part of my day.

I think about the athletes I coach -- whose "subclinical" complaints are often dismissed because their doctors know that they exercise, and are thus healthy. These folks have unique micronutrient and cardiovascular needs that are not reflected in their labs, but very much reflected in their lives.

I have a fitness instructor colleague with a history of chronic migraines. Tests to date have been normal but her entire world is turned upside down every other day. She shuts down at work, she shuts down at home. She feels powerless. As a first-year medical student, I technically know NOTHING - but I have some thoughts about the interplay of diet, hydration, the straining of specific muscles, vascular constriction, and heart rate. I don't know ANY doctor who knows any more about that than I do. Her doctors see: "athlete" and assume all that "diet/exercise stuff" is well under control and clearly not within the scope of their duties. I've certainly experienced this with my own physicians: oh, she's a fitness instructor and her cholesterol is good, no problem here... even though when my heart races and my neck has a weird bulge or I just feel generally "deficient" in SOMETHING, I am not maximally armed to navigate the challenges of my world... and it's my doctor's job to help me do that.

Yesterday, I saw a patient with a different doc at the clinic -- GI distress, vague psychosocial complaints. Labs normal. Dismissed as IBS by exclusion, and not at peace with the diagnosis at all. Expressed that she felt that she was not heard by her GI doc. THAT person -- that's the person I want to spend my life caring for.

I don't think this is idealistic to declare myself a Champion of the Subclinical. I think it's a legitimate niche population, and need to start making choices enhance my own ability to uniquely serve their needs.