Makers of Success

In the infamous exposé of medical training titled The House of God, Dr. Samuel Shem aptly refers to medical students as the perfect “victims of success.” Endowed with discipline, diligence, and a borderline neurotic pursuit of perfection, our “type A” personalities enable us to excel in the intricate realm of medical education and its practical application in patient care. These high-achieving abilities have been instrumental in propelling us forward on the ladder of success—from our initial stages as preclinical students to becoming sub-interns and ultimately donning the coveted white coat as MD graduates. However, it is crucial to acknowledge that these very enigmatic attributes can also prove to be double-edged swords, giving rise to anxiety and an incessant drive for unattainable perfection—an aspect of training that feels purposefully overlooked and dismissed. Rather than exploring this grim topic beyond an acknowledging glance, it often feels easier to shift to shinier conversations circling around, “So where are you applying for residency?”

Having an internal locus of control is one such attribute many of my fellow medical students possess. A belief that we, individually, hold the power to obtain success through diligent work, unwavering study, and decisive action. This very trait has been the driving force behind my own achievements: I firmly subscribe to the notion that the universe is not governed by randomness, but rather that each person actively constructs their life, shaping their triumphs and setbacks alike. For example, to obtain the all-coveted honors in a clerkship, it is logical to think that all we must do is act in the way that will achieve that result, studying diligently, synthesizing information, and taking care of our patients in the most exemplary way.

However, the flaws in this adaptive cognitive framework became increasingly apparent, particularly in the past month, as I embarked on the contemplation of my residency application. The process of applying to residencies seems to challenge the very essence of my internal locus of control, which I have relied upon so steadfastly. True, we do have a say in selecting where we apply and how we rank the programs. However, the initial hurdle lies in obtaining the coveted interview invitation. The stark reality of this challenge becomes palpable when one considers that some programs receive over 11,000 applications for a mere 100 interview slots and approximately 30 available positions. The sheer uncontrollability of this situation directly contradicts the very trait that has been the driving force behind my personal success throughout more than 12 years of education.

Considering this, I became startled at how easily my concept of success and locus of control became fractured when examined more deeply. The discomfort culminated as I realized that this notion's adequacy was only true when consideration of one thing occurred: privilege. Locus of control is only true for those with privilege—those, like myself, who had the ability to drive to the hospital early before rounds in order to impress the resident team, well aware that their evaluations would influence my path. There was the flaw, I realized, as I thought about a fellow student who would arrive late episodically, or fall asleep during rounds, relating that she lived far away and was dependent on the unpredictable and long bus or bike ride throughout New Orleans. To have control of one's life, or to even appear to have control, is an immense privilege that is obtained only through having the very resources that modern medical training expects one to have.

In this moment of reflection, I felt a wave of shame, a familiar sensation I've experienced in prior moments of deep introspection. It led me to wonder: How can I disentangle the relationship between control and success in this life I have diligently built? How can I understand my privilege and still be proud of all I have accomplished? How does this affect how I think about applying to residencies?

After some time, I don't know the exact answers to the questions above. However, I do know that being in this position, a rising fourth-year medical student with the promise and hope of the entire medical world and its patients before me, is an immense privilege. This resonated deeply, and the neuroticism of trying to imagine life in each city I was applying to quieted. We are on the edge of being able to care for patients in their most vulnerable state, to witness the full extent of the human condition, and to provide comfort, care, relation, and hopefully some healing along the way. While we may not be able to control what part of the country we will be living in, which relative may be close by, or if we will know anyone in our program, we do know this—we will not be the “victims” of success that Samuel Porter declared. Rather, we are the unabashedly disciplined, driven, and often-privileged makers of success. As aspiring physicians, we are creators with a profound responsibility to embrace this privilege at our very core, committing ourselves to act with unwavering compassion, deep understanding of individual circumstances, and genuine care for the entirety of our patients' being. I find comfort in the anchoring strength of this ideal as I traverse applying to residency and navigating the gregarious, messy, fantastic career that is becoming a physician.

Back to the January 2025 issue of ACP IMpact