Here is a letter I wrote to my friends and colleagues regarding my departure from clinical medicine.

As some of you have heard, I recently resigned from surgical residency, and am leaving clinical medicine.

Ten years ago, I decided to be a doctor. It was a decision that made perfect sense at the time: I wanted to help people who were suffering, and I was fortunate to have the ability and resources to gain entry into medical school. I wasn't sure which specialty would be my calling, but shortly after starting my clinical rotations I fell in love with surgery. I loved seeing and evaluating patients who had a very clear and usually dramatic surgical problem that I knew could be solved by an operation, by putting hands on the patient and potentially curing them of whatever it was that was ailing them.

I remember being a medical student on general surgery, the drama of literally saving somebody’s life, the long days starting at 4 am and ending whenever the work was done, the admiration I had of these superhuman doctors who were also craftspeople that could diagnose and treat the sickest of the sick using both their minds and their hands. They were the coolest kids on the block, and I wanted to be one of them. And miraculously, I was inducted into their world; they wanted me too, even though I didn’t necessarily fit the mold. I moved to New York and embarked on what I thought would be a lifelong journey of being a surgeon.

The things that laypeople think are difficult about clinical medicine are not the things that got to me in the end. The work-life imbalance didn’t bother me, because I thought the work was good, and worthy of doing; the long hours didn’t bother me, because it was not as if I was working 80 hours a week at a desk job; the sleepless nights didn’t bother me, because my need for rest was always superseded by somebody sick who needed my help, which was the best reason I could think of for eschewing sleep. I knew what I was getting into when I signed up for this. I loved being able to take care of people who I knew I could help, and often did. I never lost; I either won or I learned something.

But gradually, I began to see flaws in the system. One night, as an inexperienced second year resident in the ICU, the only doctor in the hospital overnight who really knew the sickest patients, I saw something on a chest x-ray that I thought was incongruent with the physical findings of the patient, and brought it up with the on-call intensivist, who dismissed it. Maybe it was because I didn’t present the situation correctly. Maybe it was because I misinterpreted the x-ray. Maybe it was because I simply didn’t have the acumen or experience to see how sick the patient really was. Whatever it was that I had done wrong, that patient ended up taking a turn for the worse, and later that week I was called in to talk to the people in the offices about it. (Very rarely does anything good come of a meeting with a person in an office.) The harshest criticism I received was not that my mistake had caused the patient to suffer, but rather, that I had not documented my conversation with the intensivist. The patient suffered in agony, and I got a slap on the wrist for not writing a note.

That was my first glimpse at the ugly side of clinical medicine. It wasn’t the last.

Over the years, more hesitancies creeped their way in. I took time off after my second clinical year to do research in patient safety. It was an amazing opportunity that I couldn't fully enjoy because I had seen firsthand just how unsafe and how unjust the system really is to patients. The conclusion that I made, personally, was that patient care was NOT safe, and making it so was an impossible task that usually just ended up in more paperwork and maybe a vague if questionable improvement in patient care. My cynical mind felt that when a patient had a good outcome, it was in spite of the system, not because of it. And the frustrations I felt as a training clinician delivering healthcare were infinitesimal compared to what patients receiving care must have felt. My days were largely spent navigating a system that was set up for me and other healthcare providers to fail. And the times that we do, inevitably, fail, whether manifest as a patient angry about having to wait in the office, one who develops a complication after an operation, or one who waits too long to get care because they are afraid that they can’t pay for it and end up with a bill ten times more than if they had been able to receive appropriate care in the first place... we as the front-line providers are the first ones to bear the brunt of the blame. The barriers to being able to spend time with and take care of patients are boundless, relentless, and unforgiving. I saw the frustrations in my attendings, too. And it wasn't just at my home institution; I saw it when I rotated at other hospitals, other programs, other systems, other countries.I have worked with so many caring, well-meaning individuals who do incredible things every day. I don’t blame any one person for these problems. It’s easy to call somebody lazy or stupid or incompetent out of exasperation, but nobody comes to work to do a bad job, and we are doing the best we can with what we have. But there are very real problems. We are in a healthcare crisis. Every once in awhile, things go right -- a young, otherwise healthy patient who comes with terrible pain from appendicitis, has an operation as soon as the diagnosis is made and goes home later that day and never has that problem again. But that seems to be the exception rather than the rule. And that is the fundamental reason why I am leaving. I am not going to have the impact I thought I would as a physician on the front lines, and I am never going to be the kind of surgeon I wanted to be when I started. Not in this landscape. This was not an overnight decision; on the contrary, it was the most drawn out, difficult decision I have ever made in my life, but it is the right one. I never imagined that I would walk away from what was once my dream, but it is no longer my dream, because I am not being the best Kwon I can be by doing this.

So. Surgery and I are getting a divorce. I still have the utmost respect for surgery, but I’m not in love anymore, and it's making me unhappy. The good days have become so few and far between that it feels shocking when they happen. Don’t get me wrong; it wasn’t all bad. In some ways, I wish it was. Because then I would have cut ties sooner, and it probably would have been easier to do so. Despite what the reasons are, we have drifted apart, and though we both fought for a long time to stay together, it’s time to end it.

I am forever indebted to the people I have met on this path who have helped me. I want to publicly thank my infallible mentor, Ron Kaleya, who has been my angel -- my neurotic, fat, balding, Jewish angel (his words, not mine). He extended a life vest to me at a time when I was drowning and it felt like everybody else was just standing by and commenting on the quality of the water. My family, who have been with me since the beginning (like, Baby-Kwon-in-diapers beginning) and who I was terrified to tell but were ultimately supportive and made it clear that my happiness matters. My sister in particular, who is my hero in life and who supported me from day one -- when I wonder what I should do, I just think about what Sarah Kwon would do, and if I don’t know what Sarah Kwon would do, I ask her, and she tells me. My co-residents, my partners in crime, my allies in this war: I commend you for sticking with it and fighting the good fight. You are battling an impossible enemy, and I have hope that you will be able to carry out the mission that I originally set out to accomplish. Same goes for the attendings who taught me: I learned something from every single one of you, and I am sure I will use the skills and lessons you have taught me in some form or another in my life. And, a very special thank you to the defectors, secret would-be defectors, and other career-changers who gave me the insight and confidence to redirect my path. You know who you are. There are more of you than I ever could have imagined, and I feel that we are bonded for life.

I am grateful to my program for the opportunity to be a surgeon, and for extending support to me even though I am no longer using that opportunity in the manner we both originally intended.

I have done and seen some incredible things as a surgical resident that I’ll never forget. I cracked the chest of a man shot in the heart. I made buttholes for babies born without buttholes (one butthole per baby). I once removed an appendix in nine minutes. I’ve seen people die in front of me. I’ve seen humans at their worst, and their best. I’ve done probably at least a thousand rectal exams (...most of them while at work). But most of all, I was given the privilege to operate on and take care of people in need, for however brief a time, in the grand scheme of things. And I am well aware that whatever struggles I had in doing so are still minor compared to the hell that patients go through, sometimes on a daily basis, for their entire lives, and unlike me, they do not have the freedom to walk away from it. They are the ones who truly suffer and my heart goes out to them sincerely.

Goodbye to surgery, and hello to whatever is next...