When I was younger, I used to so look forward to the first day of school; to the advent of school supplies and assignments and structure. However, in February of this year, I can’t say that I was thrilled to put down The Goldfinch  and pick up a syllabus that morning. Waking up and preparing for school again felt like an assault on my freedom.

For anyone who’s been there, fourth year is so  unstructured — you’ve survived 75% of your USMLEs, and are now in a string of pass/fail clerkships punctuated by periods of travel and self-discovery. I came into that environment after a research year, during which I structured my time as I saw fit and did so both happily and productively.

When February hit, I wondered, “Is this how it’s going to feel every day for the rest of my life, now that I’ve had some time to experience what life is like when you don’t live and die by your study schedule?”

I spent two months gratefully traveling around the country for my residency interviews, telling everyone the politically correct reasons for which I have always wanted to be a dermatologist.

I talked about how, as a kid, my dad’s nickname for me was “puzzle head” because I could typically be found at the dining room table obsessively hovering over a 1000-piece jigsaw puzzle. I talked about how I learned — during the third year of medical school — that I value continuity of care, forming relationships with people and getting to know their stories over several visits, and the gratification from seeing a disease resolve from the outside-in (as happens when improvements in skin conditions can often render the entire psyche uplifted and transformed). I talked about all the patients I saw in Tanzania, where I lived for a total of four months during medical school and learned more about myself than about the specialty that I’ve ineffably wanted to pursue for nearly a decade.

But the real reason, the one to which all of my friends, family, teaching assistants and professors have been privy all along, is this:

Throughout college, when I was spending 80 hours in the library, studying without pause or regard for a reasonable work-life balance, I punctuated the time by watching videos of abscesses being drained and ingrown hairs being removed.

The only thing that sustained me, at times, was the knowledge that, if only I worked hard enough, I could someday be the one responsible for treating the “gnarly surface manifestations of disease,” as I so carefully referred to them in my personal statement.

Why have I spent so much of my life trying to live up to an image of what the “right reasons” are for doing what I want to do?

I just want to take care of people and drain pus. Isn’t that reason enough? 

• Why is it so hard to say what we mean?
• Why is it so hard to tell the truth?
• Why is it so hard to call a spade a spade?
• Why is it so hard to say: “I’m sorry that you’re dying and I can’t fix it, but I still want to work hard to make you feel like your best self with whatever time we have left together…”?

I have come to think that it’s really hard to pursue a career in medicine for the “right reason” at all, because the path starts so long before your brain matures, before you’re able to develop a conception of what it means for you to flourish, before you’ve stopped using “fear of failure” as your primary source of motivation.

When I became a pre-medical student in college during freshman orientation, it just sort of happened.

There was no “moment of clarity” when the clouds parted and it became clear to me that I was being called to pursue a career in medicine. I liked school, and I liked being respected, and I liked feeling useful. In truth, up to that point, I had very little identity outside of being a student. Emotionally, this left me pretty stunted and immature. And yet, on the surface, I had a reputation for always having my … “stuff” … together.

My general chemistry professor was the first person to ask me why I wanted to be a doctor. His reputation for making pre-meds cry — rumored to be a side effect of his inability to gain medical school admission thirty years previously — preceded him. But for some reason, I felt secure enough to have a conversation with him. As he broached the subject of “why medicine,” I felt the words spilling out of my mouth faster than I could grab them and place them into the proper order: “I just want to help people.”

I left the meeting crying. It was clear to me that, whatever motivation I ultimately arrived at for wanting to be a doctor, I shouldn’t express it quite like that.

Fast-forward nine years and 2000 miles to the Northeast, to where I stand today.

Lately I have been wondering whether, “I just want to help people,” is in fact just code language for:

“I have a codependent personality and my identity is rooted in making sure plenty of people need me so that I can focus all my energy on making them better without having to actually take care of myself.”

“Pardon me while I have another nervous breakdown over scoring an 88%.” Or, in short, “Hello, my name is Sarah Jane, and I have a savior complex.”

(Hi, Sarah.)

I have come to believe that many physicians are motivated at their core by the desire to put everything back together again, as if the world is our Humpty Dumpty. And I think that makes it really uncomfortable when someone is dying and we cannot fix it. And so we find ourselves fumbling our arsenal of facts and using rose-colored versions of reality to approach patient care. The truth is scary. Patients seem to be simultaneously demanding the facts and  good news.

When you spend your life jumping through hoops and pleasing everyone to get by, it becomes especially hard not to be able to give people what they want in these scenarios. What I have seen on the floors over the last few years have been a series of neurotic defense mechanisms as responses to these dilemmas: intellectualization, rationalization, frustration, circumvention.

But, the truth will set you free. (Typically right after it pisses you off.)

Because a funny thing happened when, twice during the interview season — once at a preliminary internal medicine program and again at my number one dermatology program — I was asked specifically what I had meant by, “the gnarly surface manifestations of disease.”

As if a wall had come crumbling down, I admitted to my interviewer what I had meant: “Well I sort of have always loved draining pus and cleaning things up and taking stuff out of where it doesn’t belong I looked up in each instance, horrified that I had overstepped the boundaries of professionalism and entered into the realm of creepy, only to find the interviewer smiling back at my honesty.

Perhaps my honesty during these encounters is inextricable from the fact that I am ranking them each number one. I felt like I could be my true self, and, quite frankly, I have grown tired of being in situations where I don’t feel this way.

So, while we’re on the subject, here are some more spades:

I’m really scared that I’ve spent too much of the last two years discovering who I am and how I flourish, and now I won’t be a good doctor because there are too many other things that I love doing.

Because being a good doctor is about putting your patients first, and this means reading journals in your spare time and staying up to date on the latest developments and seeing extra cases and taking your notes home with you  right?

I don’t feel like I’m professional (read: stoic, self-sacrificial, uni-dimensional) most of the time, at least not enough anymore to be a leader in dermatology.

I’m not sure where my career is headed, but I hope it’s not to places where — because of unfounded ideas about the way that I “should” be — I become afraid to be real.

Med School Tutors Editorial Note:  Sarah matched at her #1 dermatology residency choice — UCSF. Look out, “gnarly surface manifestations of disease.” Sarah Jane’s coming for you.