I am surrounded by unhappy physicians. I am not referring only to those physicians in my immediate sphere of acquaintance, such as the members of my specialty or the hospital or even the county medical society. The boundary of this unhappiness appears unlimited in my estimation. However, if asked for a specific boundary for the purpose of discussion, it would seem safe to include the physicians who practice medicine in the San Francisco Bay Area. This must include a few thousand physicians, accounting for an astonishing amount of unhappiness. How can this be?

I have heard my fellow physicians complaining of feeling powerless in the face of the recent changes in medicine. I have read articles in medical publications that speak to the frustration and anger that physicians are experiencing. That this anger extends beyond my immediate associates was demonstrated in a series of columns that appeared in the local newspaper a few months ago. At that time, seemingly untold numbers of readers, including physicians, felt the need to vent their anger and frustration. It was not always like this.

I can remember what it was like when I first started private practice eight and a half years ago. I recall that the medical staff was excellent. There existed a sense of camaraderie and benevolence that was sweet music to the soul of a physician straight out of a county residency program. The atmosphere was upbeat, the availability of high-quality consultants exceeded expectations, and the focus was clearly on delivering the highest quality of medical care possible.

What a crying shame that much of this has been lost! The same physicians remain in their roles, carrying out the duties that their respective specialties have assigned to them, only doing it with evident toil, frustration, and increasing fatigue. That they remain committed to delivering quality medical care is the single constant factor that has been sustained over time. They are increasingly hampered in their efforts to achieve this goal. This is the greatest source of their unhappiness. Why do they choose to participate in a system of medicine that is the source of such unhappiness? Why do they feel powerless? Who has given them this mistaken impression? Why do they remain silent? Why the denial? This entire evolution of the practice of medicine depends absolutely on the physicians' voluntary participation in all of the various rules and regulations. Since it is the source of so much profound exasperation and frustration, why do they continue to participate? The answer lies in acquiring an understanding of the process by which physicians receive their education and training. For it is oftentimes the case that during this lengthy and arduous process the individual loses his or her sense of power, self-esteem, and own voice. This happened to me.

It happened so gradually that I am not able to pinpoint the moment in time at which it occurred. I can recall specific contributing examples. I was first made aware of it approximately two years ago. I was involved in community work, and a very dear friend bluntly stated that I had "lost my voice." I felt the greatest surprise. What could he mean by this? I was perfectly capable of speaking and expressing my point of view. I was capable of communicating well with family, friends, and patients. I was capable of carrying on a good conversation. I puzzled over this comment for many weeks until I discovered what it really meant. The loss of one's voice means the loss of being able to express one's inner feelings and thoughts. In addition, it follows that one loses the ability to recognize them as having validity or importance. For myself personally, it meant that I had stopped believing that what I thought or felt might actually be interesting to anyone else. Loss of one's voice can be seen to go hand in hand with the loss of one's power. I began to reflect upon my life to determine when this had occurred. For, once it was pointed out to me, I could see that this observation was correct. How and when had this happened to me? It was important to discover the reason.

I reviewed my childhood and adolescence, and as I reflected on the person that I was at eighteen-exuberant, lively, feisty, and ready to have a run at life-I realized that my voice was intact at that point. I remember my college experience as the happiest of times. I had many friends, and we enjoyed ourselves and our adventures immensely. I was able to excel academically and gained admittance into an excellent medical school. I remember the privilege of associating with such a talented group of diverse and interesting classmates. The first two years of medical school offered associations and adventures of a different kind, though still enjoyable. I then recalled and mused over the last two years of medical school and my residency experience. These years should be grouped together, because they represent a continuum along the path of learning clinical medicine. It was at this point in my reverie that I realized with a sense of foreboding that I had come to the answer. It was during these years that I had lost my voice. I realized that it was the price I had to pay in order to receive this most wonderful and unique of all educations-I must add, however, that this price was too steep. I will recall only two instances to exemplify my point.

The first example occurred during my third-year clerkship during general surgery. This happened to be my first rotation, and I was so excited about finally learning what it was going to be like to become-at last-a real doctor! General surgery is an exciting rotation, the residents were always very busy "doing something," and the Attending Physicians were very important personas. I enjoyed my time on the rotation immensely, except for one episode. It occurred during an operation. It was generally assumed that we could expect a pop quiz on the particular anatomy at any given time. We were expected to answer correctly and were very much motivated to leave a good impression on the Attending Physician. This accounted for many late-night reviews of the particular anatomy of the planned case for the next day. All of the medical students wanted to make a good impression, and we were eager to please. I suspect that our demeanor was viewed much as one views the mannerism of puppies. We were naive as well. I remember being in my surgical attire and being "scrubbed in" on a particular case when I was asked a question. I ventured an answer, but in my state of nervousness and from my desire to get it just right the wrong answer was given in a nervous stammer. I was laughed at. It was a quiet little snicker from the Attending Physician. The scrub nurse joined in with a comment of her own. I was humiliated. I could feel the tears stream down my face and was at a loss as to what to do next. No further commentary was given. I was left in silence to ponder my ignorance.

It was one of my first lessons: Do not be too eager to speak up. When you are trying to say what you really think and feel, do not leave yourself too vulnerable-you might be in for a nasty shock. I was left to ask my dear and kind resident for advice regarding this incident. "Act like a duck," he said. "Learn to let the water run off of your back. Toughen up." There would be more of that type of incident to come in the years ahead.

The second episode occurred in residency. Again, it occurred in my first rotation. I was in a clinic that treated pregnant women with high-risk medical problems. I had been a "real" doctor for just one month. I remember having a great curiosity about these problems and began asking questions. I was motivated to learn as much as possible. After all, this is what I would be doing for the rest of my life. I recall being made to feel completely inadequate at my lack of knowledge. This was communicated to me in such a humiliating and biting manner that I was brought to tears on more than one occasion that [first day]. I left the clinic more than once to seek solace in the graffiti-covered walls of the county hospital rest room. Once I regained my composure, I was able to return. I barely survived that grueling day. The fact that I would have to return to the clinic and face repeated episodes of this type for the remainder of the month's rotation was extremely depressing.

I survived this experience by learning not to ask any questions, not even the most important ones. I remained as quiet as possible, like a mouse, so as not to bring any undue attention to myself. Any subsequent negative commentary brought back the words of advice from my medical school experience: Act like a duck, do not let these people [get] to you; toughen up. Easier said than done for this sensitive soul.

I mention these stories not to cast any negative thoughts toward these Attending Physicians but rather to illustrate what actually happens to residents and medical students during training. I feel that both Attendings felt as if I needed to toughen up. This was their manner in teaching me that lesson. The lesson was learned at a great price.

To complete this picture, I need to mention the conditions under which interns and residents actually work. It is fairly commonplace to expect interns to work a minimum of twenty-four hours, if not longer, at a single time. In addition, this shift is to be worked with no actual expectation of sleep or food at any regular or predictable interval. It is also to be worked without complaint, if one is to be considered a [good] intern. It is not just one twenty-four hour shift that is expected. It is a sequence of many, over and over again, during the course of a minimum of three years. That truly compassionate physicians can emerge from this environment is a testament to perseverance against all odds. I am pleased to say that I know many such survivors. However, even these survivors may not realize that, while they were able to emerge with their compassion intact, they may not have retained their voice. A price was paid.

It has occurred to me lately that once individuals are subjected to this type of dehumanizing treatment and "abuse," they are susceptible to being taken advantage of subsequently. In a manner analogous to victims of child abuse who then grow up to enter dysfunctional relationships, I see that my colleagues have done the same thing. I am speaking of their relationship with the HMOs in particular, and with the insurance industry in general. Having lost their sense of power and control over many routine and ordinary acts of the day-added to these individuals' having also lost the right to express legitimate questions and concerns-has made these physicians ripe for the picking. How else to explain their participation in a health care system that causes them so much grief, that causes them to question why they went into medicine in the first place, and that allows them to continue to participate when so many members of the outside community are raising serious questions? It has occurred to me lately that practicing medicine under managed care rules and regulations is bringing back many unpleasant associations from residency. Voiceless . . . powerless . . . dehumanizing . . . intolerable.

When will all of this stop? When the physicians realize what has happened to them and truly understand why it is they continue to participate. It is their [voluntary participation] that makes the entire system work-as well as their [continued silence]. When will they realize that, like Dorothy in [The Wizard of Oz], they are already wearing the ruby slippers?