A Young Doctor's Hardest Lesson: Keep Your Mouth Shut

By Kent Sepkowitz, M.D.
Published: NY Times, December 28, 2004

An unspoken but ever-present issue in the life of any doctor is an immodest, completely nonmedical concern: are doctors boring people?

Sober and serious, surely. Respectable and educated, one hopes. A bit stuffy at times, perhaps. But dreary?

As a profession, I think we do tend to run on the dry side, though till recently the reason had eluded me. Then, last month, my wife and I bumped into an acquaintance of hers while walking along the street. The person, unbeknownst to my wife, is a patient of mine, someone whom I treat for a chronic infection. After the patient and I shared a moment of mutual panic, we three chatted amicably and moved on.

Except, that evening, my wife kept asking me why I was being so quiet and, well, boring. And I suddenly saw the problem: doctors are waterlogged with secrets, hundreds of them, thousands of them.

Each day brings a new batch: patients' admissions about drug use or sexual indiscretion, a hidden family, a long-held dream, an ancient heartache, undisclosed H.I.V. infection.

Over the years, this begins to add up, the bulge expands, the joints get stiff. Yet the secret - the consequences of our ever-expanding repository of others' secrets - remains, well, secretive. The situation simply is not addressed, not at the start, middle, or the end of a career.

The most difficult aspect of a training doctor's life is not suddenly bearing witness to someone else's pain and death; it is not adjusting to arduous work hours; it is not the imposing amount to be learned and synthesized. These surely are intense, life-transforming endeavors but are still related to other experiences.

No, the biggest shock along the road to becoming a doctor is the startling revelation that you can ask and the patient will tell anything. Young doctors, when they first meet patients, don't know quite how to react. After all, most people are raised to be careful in their interactions, discreet in their inquiries, fair-minded in the way they might pursue personal information.

Now, suddenly, everything goes. As doctors, we can and must ask a battery of questions about last weekend's big night out, about how that rash may have occurred, about why you have been sniffling for so many months. And sure enough, right on schedule, most patients answer with little or no discomfort.

But with this intoxicating power comes an equally strong interdiction: shut your trap. You can ask what you want but you'd better keep quiet about it.

A person's trust in you, in medicine, in society's ability to assure someone's safe passage through illness requires learning quickly how to keep secrets.

This sober business of maintaining confidences is the closest we come to the priesthood. Forget healing, forget laying on of hands: it is the importance we place on silence that is our most important spiritual activity.

Yet the world offers few hints (or incentives) on how to button your lips across the decades. Indeed, we celebrate the most unbuttoned among us: movie stars and gossip columnists, Barbara Walters and blabby neighbors.

How much juice can they squeeze out of someone?

Other professions that traffic in secrets typically maintain silence for a fixed period: lawyers and spies, accountants and politicians, mobsters and four-star generals. Power or leverage is at stake, but once things settle, the gabfest can resume.

But for us, the silence is forever. The consequence of this tight-lipped life is readily evident anywhere young doctors have congregated. Exploiting the single loophole in the code of silence - chatting up one another - they busily swap stories about patients. Near-maniacal peals of laughter are heard as the latest "I once saw this woman in the E.R. who" tale is recounted.

The hilarity, the need to yelp, surely derives from something other than the quality of the story at hand. I know this because, um, I have transgressed a few times, to try out a story on someone not medical. And rather than hearing the appreciative party guy hoot of laughter, I receive only a confused squint.

So we learn to keep quiet about the whole thing, trusted advisers in the persistent palace intrigue. But conducting business this way is confusing. What is off limits, and what remains in play? Can I say this or that?

Pretty quickly, it becomes clear that the easiest and safest - though the quietest and dullest - approach is simply to shut up concerning just about everything.

It makes for some admittedly dim evenings, perhaps, but at least this way everybody's odds and ends stay locked up and out of reach.