Residency as Identity Transformation: The Life Stages of the Homo medicalis.

Abstract

O ur appreciation of human life cycles and stages is about 150 years old, contrasted with hundreds of thousands of years of human existence. We recognized that children were not small sinful adults, as the Victorians preferred to view them—not homunculi, but in a developmentally distinct phase in human growth. This was the beginning of understanding human development and distinct stages in a person’s life. Along came Freud, who further defined the stages of human life with the childhood developmental stages of oral, anal, phallic, latency, genital/ puberty and adolescence, followed by adulthood. The stages of child development were expanded by Freud’s daughter Anna, who essentially revealed the life of the mind of a child. Freudian pioneers like Peter Blos and August Aichhorn revealed that adolescence comprises many substages; they elucidated the concept of adolescent ‘‘acting out’’ through delinquency and that these rebellions are transient in many. Anna Freud felt that the stage turmoil of adolescence is so profound that one should be wary to render a diagnosis during this life cycle, for even psychotic symptoms could disappear. These important pioneers of the human psyche revealed the developmental stages and cycles of life and defined them by affective and cognitive milestones. The concept of life cycle, stage, milestones, and ongoing development was further pioneered by a student teacher in Anna Freud’s school for children. Erik Homburger Erikson, who as a developing and unemployed artist found employment there through his friend Peter Blos, discovered psychoanalytic adolescence. Erikson understood that life cycles do not end after adolescence and that distinct cycles with needs, goals, and crises continue until death. It is unclear to many in the field of life stage psychology when these stages begin and end, and adolescence until age 30 is not unusual. Also, each stage develops an identity that does not disappear completely when the next one begins. The structures of the prior stage can be changed, altered, sculpted, and carried wholly or piecemeal into the next cycle. This profoundly alters our view of the power of the life stage/cycle, for the effect of prior stages does not die or wither away but remains an active influence. How active these life stages are, their ultimate complexity, and their relevance to understanding the human psyche, behavior, cognition, and identity needs appreciation. This may help us better understand medical residency as a life-altering and identity-transforming period in a young person’s life. Residency is where young people with a medical degree actually assume the personality and identity of ‘‘doctor’’ in its first and perhaps final incarnation. However, this fact seems to be contested by many for a host of reasons. First, we divide and famously compartmentalize our lives into work, personal, family, civic, and community components that we view and respect as separate. Second, we struggle and bumble over what is legal reality versus what are social, psychological, and biological realities. The legal opinion on the status of teenagers and young adults in school, college, and residency, versus the learners’/trainees’ relationships to their teachers, bosses, and leaders, appropriately but confusingly protects young people by determining that teachers are not in loco parentis. This important legal precedent—established to protect the autonomy of susceptible youth and to avoid abuses— ultimately drove wedges and schisms into real and lifealtering influences by role models. Embracing the precedent, teachers refuse or demur the role of models and accept a distant relationship with trainees; for they are not the biological parents, though they are surely the trainees’ role models, with life-influencing and sustaining impact throughout their lives. This abrogation of strong bonding relationships was a relief to and a lesser emotional burden on teachers that allowed them less authority and blame within the lives of young people, with the concomitant diminished influence and likelihood of accusation or possibility of injury, trauma, or abuse to young developing identities. Another of the many wedges between trainees and teachers in medicine was Osler’s historically dominant yet contested essay Aequanimitas, in which Osler prescribed an emotional distance. The pre-Flexnerian and peri-Flexnerian eras were rampant with mysticism, magic, varieties of alchemy in the practice of medicine (including hysteria), and charismatic and uncontrolled emotionalism on the part of both patients and doctors. Osler’s Victorian and maledominant ideas of the time attempted to introduce the Jacob J. Steinberg, MD, is Professor in the department of Pathology at the Montefiore Medical Center of Albert Einstein College of Medicine.