Every budding medical student prepares for this inevitable question.
Interview training advises against parroting the clichés of ‘an equal interest in people and science’ or following in parents’ footsteps, and especially against confessing to a desire for the social status and financial rewards offered by a career in medicine.
Of course, the latter is almost always important, a fact known to both parties, despite remaining unspoken at interviews.
Perhaps there are other, more profound and less acknowledged, reasons for going into medicine: reasons that are closer to the truth, but that are present to varying degrees in the candidate’s conscious awareness.
One possibility is epitomised by Alice Miller’s concept of the ‘parentified child’. Miller described children who were preoccupied with looking after their parents, rather than themselves, as they grew up. This may lead those children to instinctively choose to carry on this role by caring for their patients. Whilst this process can produce dedicated doctors, the individual involved may harbour unconscious resentment towards their needy parent for denying them a full degree of freedom in life.
The deeper reasons for choosing medicine often involve processes predominantly in the unconscious mind, a concept famously explored by Freud. In Freud’s so-called structural model, the mind is divided into the id, ego, and superego. The role of the mostly conscious ego is to reconcile the demands of the unconscious id (which seeks out immediate gratification of our instinctive drives), the mostly unconscious superego (which acts as a sort of moral conscience), and the external world.
This balancing act can be challenging. To avoid anxiety, the ego employs defense mechanisms to manage unacceptable impulses from the id. One such defense is sublimation, which involves converting unacceptable impulses into more socially acceptable activities. A possible (controversial) example in medicine is someone with sadistic impulses of cutting others training to be a surgeon.
Another form of sublimation is the altruistic defense, in which helping others is a means of pushing our own needs and anxieties into the background. Doctors employing this defense avoid their personal difficulties by expending energy on investigating and treating the problems experienced by their patients.
A further example of sublimation involves the more complex psychological idea of reparation. Described by Melanie Klein, reparation is the wish to heal the damage caused to a loved person.
The archetypal example of this process occurs in the infant, who, before realising that good and bad can exist in the same person, idealises the parent who feeds, and hates the (same) parent who does not respond instantly to his needs. When the infant later realises that he has wished harm on his loving parent, he feels guilt (or depressive anxiety), and from this guilt is born a desire to reparate.
Thus, a doctor may harbour anxiety about destructive impulses, or supposed harm caused to loved ones, and unconsciously relieve this anxiety through repairing, or healing, his patients.
Reparation is a natural impulse but can be contrasted with the less mature ‘manic reparation’. A person who uses manic reparation is unable to tolerate the ambivalence of a flawed (that is, both good and bad) loved one. This person feels, according to Hanna Segal, ‘a triad of feelings – control, triumph and contempt’ towards the loved one. This renders the damage that he feels that he caused irrelevant, and he thereby avoids uncomfortable feelings of guilt. The damage, though, is never repaired, and there is endless repetition of this process—whence the term ‘manic’. It is worth reflecting on this theory when recovering from an encounter with a difficult, defensive, and authoritarian hospital doctor.
Another possible reason for pursuing medicine is encapsulated in a biblical proverb, ‘Physician heal thyself’ (Luke 4:23). Understanding and empathising with the difficulties of others offers an opportunity for profound personal growth. Carl Jung thought that the goal of life is the integration of the unconscious and conscious in order to become a whole, differentiated person, a task that he termed individuation. He saw the old idea of alchemy as symbolic of the transformation seen in individuation. The processes involved in turning base metals into noble metals he saw as metaphors for processes occurring in the psyche. Alchemy could also represent the joint healing of the doctor and patient through a combined therapeutic journey. Just as a base metal may be heated, crystallised, sublimated, distilled, and refined, so the doctor and patient may metaphorically come together as clothed strangers, become naked, join in union, reach the depths of their unconscious, and, finally, emerge together more noble, truthful, and divine.
“Your vision will become clear only when you can look into your own heart. Who looks outside, dreams; who looks inside, awakes”
– Carl Jung