I used to think medicine would change me by adding things. Knowledge. Confidence. Authority. Certainty. I assumed growth would look like accumulation, more skills, more answers, more control. What actually happened was the opposite. Medicine changed me by subtraction.

When I started writing as a medical student, everything felt sharp and exposed. The hospital was loud, inefficient, and often cruel in ways no one named out loud. I wrote about scut work, hierarchy, exhaustion, and the quiet violence of bureaucracy because those were the things that felt most real. I was idealistic, but already skeptical. I still believed competence mattered, that suffering deserved dignity, and that good intentions could survive bad systems if you were just honest enough. I also believed that if you worked hard and cared deeply, the system would eventually meet you halfway. That belief did not survive intact.

Adaptation and detachment

Over time, I learned that medicine rewards endurance more than insight. It tolerates moral clarity only if it stays polite and quiet. I watched good people become smaller versions of themselves in order to function. We enter medical school believing the patient’s story matters. We leave training being taught to interrupt them after 11 seconds of talking. No one frames this as teaching you to stop listening. But that is what it is. I learned, like many do, how emotional detachment can masquerade as professionalism. At first, that detachment felt like a loss. Later, I understood it as an adaptation. You cannot absorb everything and survive. But you also cannot turn off everything without losing something essential.

What changed most was not how I practiced medicine, but how I understood my role within it. I stopped believing that being a good doctor meant being endlessly available, endlessly agreeable, or endlessly resilient. I stopped confusing self-sacrifice with virtue. I became less interested in being seen as caring and more interested in whether care actually happened. That shift was uncomfortable. It stripped away a lot of external validation. It also made me more honest.

The clarity of constraints

Working in correctional medicine, military medicine, and low resource environments accelerated this evolution. These are places where systems are bare, incentives are obvious, and outcomes are hard to spin. I have examined wrist nerve injuries from days in four-point restraints (inmates in physical revolt against solitary confinement) then returned to my note to adjust their antidepressants. You see quickly what matters and what does not. You learn that documentation does not equal care, that protocols do not equal judgment, and an algorithm optimizes for whatever its designers told it to value.

You also learn that dignity is not a feeling. It is something you actively protect, especially when no one is watching. Protecting it sometimes means quiet institutional disloyalty: explaining a grievance process to someone living in 110-degree heat, naming years-long delay in care as neglect, refusing to order meds for a death sentence, saying out loud what the chart won’t. The system does not reward this.

I no longer write from the posture of outrage. Not because the problems have softened, but because outrage burns hot and brief. What replaced it is something quieter and heavier: Responsibility. I care less about exposing broken systems and more about building or shaping things that reduce harm, even imperfectly. I am more cautious with certainty. More comfortable with limits. More willing to say no.

If there is humility in this evolution, it comes from recognizing how little control any individual truly has, and how much influence still exists within constraints. If there is insight, it is this: Medicine is not redeemed by idealism alone, nor destroyed by cynicism. It is shaped, slowly and unevenly, by people who decide what they will and will not participate in.

I am no longer looking for medicine to define my purpose. I am trying to be useful within it without being consumed by it. That may not be the arc I imagined early on, but it is the one that feels honest now. And honesty, it turns out, is harder to maintain than hope.

Justin Sterett is a correctional physician and a flight surgeon.