The trial will destroy most of them, but they persevere anyway. Every year, king salmon begin a 2000 mile journey upstream to the brooks from which they were born. They collect by the thousands at the mouth of the Yukon River, thrash their way upstream against the powerful current, jump with powerful flicks of their tails over high falls and churning rapids, are killed by the hundreds by bears and bad weather, die of disease and exhaustion, are trapped behind barricades too high for them to leap. Only a remnant of a remnant ever reach the goal they seek.

Every year brings a fresh crop of first-year students determined to make it to medical school. Like salmon, the trial will destroy most of them, but they persevere anyway. Courageously they burst forth onto the first day of classes, thrash their way through Physics and Orgo and Bio, leap past midterms and MCATS, struggle with the conflicting currents of extracurriculars and academics. Few get a chance to try leaping past recommendations and personal statements. Even fewer get the chance to run the rapids of secondaries and interviews. They struggle, they thrash, they leap over bar after bar, they fail, they transfer, they drop out, they sometimes even, horribly, kill themselves. Only a remnant of a remnant ever reach the goal they seek.

When we all started college as pre-meds, I remember freshmen who swore they would never turn into "grade-grinds," that they would balance a social life with pre-med. I don't see any of them here at the finish. I remember those who thought they could have both romance and pre-med, both fun and pre-med, both social life and pre-med. I don't see them here now. Life, a good friend of mine once remarked, is like an auction. Whoever is willing to pay the highest price for something - be it suffering, misery, or yes, even death -- will get it.

But even among those who do work hard, who spend four years doing their work and volunteering and researching and groveling, most still will not make it. The process destroys the slackers and the grade-grinds, the proud and the humble, the generous and the cut-throat alike. There are easily ten people who could have been far better doctors than I could ever be, but are not in medical school because of one stroke of bad luck or one bad judgment call. I do not deserve my fortune anymore than they deserve their disaster; only luck separates the survivors from the perished.

So why do we do this? Why do we turn what could be the best four years of our lives into a constant, desperate midnight struggle? Why do we sacrifice friendships, love, joy, health, sometimes even life, for the hope of a single thick envelope in the spring of senior year? And why do thousands of freshmen continue to try to do the same thing?

Why do so many of us want to become physicians?

Despite the question, this essay is not going to be the standard medical school personal statement. When medical schools request a personal statement, they don't really want to know why you want to be a doctor. The admissions committees want to know why you are better than all the other candidates. A successful personal statement discusses extracurriculars, special skills, research experiences - activities that make you stand apart from other medical candidates. A successful personal statement spends very little time discussing what motivates those activities. After all, we want to go to medical school because we want to help people, right?

That's what every pre-med says. But behind all of the prepared answers and fixed smiles churn complicated human hearts. There are always deeper reasons to go into medicine, reasons that do not fit on a double-spaced page and that admissions committees do not care about. Many non-physicians (and non-pre-meds resentful of the curve-breaking hell-for-leather study habits of successful pre-meds) believe in their heart of hearts that people enter medicine for reasons other than altruism. After all, you don't see huge crowds of people competing to become social workers. You don't see tons of parents telling their kids to become high school counselors. It is those other rewards - the money, the respect, the security, the lifestyle - that really draws forth the pre-meds with dollar signs in their eyes, right?

Dead wrong, even if most non-pre-meds don't know it.

It is not for the money: the rise of capped fees per patient means getting proper care for HMO-based patients will require extra money spent out of the physician's pocket. The shift to managed care means physicians will subtract those extra costs from fixed salaries. And the inexorable growth in bureaucratic expenses and malpractice insurance premiums will only continue to squeeze patients and physicians alike, and have already made some areas too expensive for most physicians to practice in.

It is not for respect: the rise of for-profit HMO's and their dehumanizing cost-cutting measures, the proliferating number of HMO-mandated gag orders and denial of care decisions, and the effects of aggressive litigation are leading patients and the public to resent and fear organized medicine. Patients will legitimately wonder how much of what the doctors say is scripted by their insurance company, how much is conditioned by the malpractice lawyers, and how much is the truth.

It is not for the security: between fatal needle-sticks from AIDS patients and deadly infections that shrug off all antibiotic assault, medicine is becoming downright dangerous to its practitioners. Add to that the insecurity caused by the financial shenanigans of profit-hungry HMOs and the looming spectre of nationalization of the health service, and medicine becomes a downright difficult profession to plan a future in. The days in which a physician could hang up his/her shingle, begin a family, and expect to see the same patients for decades died with the record player.

It is not for the lifestyle: between under-staffing due to funding cutbacks, and the shocking increase in uninsured patients suffering from severe gun, drug, or sexually related illnesses, doctors can expect to be on their feet for up to 36 hours at a time - and then are expected to struggle with paperwork, budgets, and everyone's lawyers after work. There once was a time when the end of medical school meant the beginning of three-day work weeks. Now, my two cousins are almost three years out of medical school and still don't have Sundays to call their own. Not to mention one-hundred-thousand dollar debts making it impossible to afford a new car, let alone a family. And personal lives? Not when you're spending every waking hour scheming to make too few resources save too many people. The hospitals of America are becoming war zones - so much so that the United States Army trains its own combat surgeons in American inner-city emergency rooms.

The television show ER, long respected for its realistic view of today's medicine, portrays these problems vividly. All of the doctors portrayed on that show have shattered personal lives. Failed marriages, abandoned parents, massive debts, violent patients, broken friendships, death from AIDS and senseless violence; these are the things these physicians have to show for their years of work. The awesome stress wears down and destroys even those who have spent their whole lives to become physicians. In fact, the creator of ER, Michael Crichton, was himself a Harvard-trained physician who burned completely out a few years after graduation and turned to authoring instead.

All of us who take the pre-med path could easily have applied our talents to professions that would offer far greater financial rewards, less uncertainty, and less threat to our lives. My cousins in residency have already spent nearly seven years in training since medical school began, now make only about $30,000 dollars a year, are tens of thousands of dollars in debt, and have had little time to call their own. Friends of mine who have graduated with electrical or chemical engineering bachelor degrees just last year are now making $50,000 dollars right out of college and expect six-digit salaries in three years, have had their college debts and future graduate school costs assumed by their employers, and complain that they have too much free time after work and nothing to do. For all of these reasons, countless physicians have told me not to follow in their footsteps. My parents wanted me to attend Harvard or MIT and become a lawyer. So why do we and thousands of others still try to become physicians?

That is what I hope to explain by writing this essay. I don't presume to speak for anyone else. I do suggest that what drives me is not unique.

The metaphorical journey to accomplish the heart's desire is an ancient one. If life is an auction, then men and women have been wagering everything for various quests for thousands of years. In his poem "Ulysees," Tennyson wrote about the mythical king of Ithaca of the same name, whose 10-year quest to return home from the Trojan war became the basis for Homer's Odessey. In the Odyssey, Ulysses, driven by the memory of his wife Penelope, perseveres homeward against insane odds and the active opposition of several Gods. Ulysses perseveres homeward even when offered immortal life living with the voluptuous and madly-in-love goddess Calypso. Ulysses risked and gave up everything just for the chance to return to his beloved wife and family.

In Tennyson's Ulysses, an aged Ulysses, in the final days of his life, embarks on one last journey into the unknown. His wife is dead, his son has grown into a wise and effective successor; Ulysses has no more responsibilities to fulfill in his homeland. He could have easily spent his last days in ease, enjoying the fruits of his long life. After twenty years spent away from home, after his travails returning from Troy, Ulysses could be excused if he chose not to end his days sailing a flimsy boat into uncharted tempests.

What Ulysses, through Tennyson, speaks for is something ageless and uniquely human. For Ulysses, something irresistible draws the aged master mariner out for a journey that will last until he dies. We pre-meds too are drawn forth by something irresistible for a journey, the quest to become a good physician, that will last the rest of our lives. We and Ulysses share the willingness to trade comfort and ease for something harder, harsher -and more rewarding. This common bond is what makes his journey until death a metaphor for ours.

What is it that draws us on? Money, respect, security, lifestyle? Not at all. Ulysses dismisses a lifetime of such honors in three short lines; medicine today buries such honors under a mountain of responsibility and trial. Such things could be had without risking all in a journey lasting until death.

Perhaps it is not for anything real, countable, priceable. For Ulysses, both the joy of fighting alongside men he trusts for something they believe in, and the wonder of pursuing the unknown, was enough to leave his wealth and comfort behind. When Ulysees looks back, what memories of his journeys away from home does he treasure? Not the many honors he received as Ithaca's king, not his years with the impossibly beautiful nymph Calypso. Of all of the things he has done in his long lifetime, only the adventure and the camaraderie of the war at Troy is worth recalling by name. For me too, the joys of working with others have been at the heart of my most memorable experiences.

I hear the cynical among you grumble: "Don't tell me what you believe; tell me what you do, then I'll know what you believe." Fine. I said some of the most memorable experiences of my life came from helping others. It would only be fair for me to share some of those experiences, and let the reader decide what he/she may.

On my desk is a long color print of myself, my friend Shinji (now a senior at the American School in Japan, my alma matter), and 15 grinning second graders. That picture recalls memories of trying to convince those 15 second-graders to eat their vegetables. With a ketchup-smeared grins, they held the hated cups of beans and peas over the trashcan. "Nokoshite iee?" (Can I toss it?) they asked. My campers were always full of questions: "Do I have to eat the vegetables? What was an American college student doing at a summer day camp in Tokyo?" For four weeks last summer, I sculpted dinosaurs, shot hoops, and caught dragonflies with a dozen rambunctious Japanese elementary schoolers no heat could slow. Helping them learn English, master juggling, and practice roller skating filled each day with new questions and challenges. I loved every minute of it.

Another experience forever changed the way I looked at Tokyo, my family's home for five years. The most convenient way to travel around the city is by riding the metal-grey trains that snake under the streets. Beneath the skyscrapers and million dollar a square foot department stories, streams of commuters pulse to and from the city through arteries of concrete. Uniformed school-girls, business-suited sarariman (salarymen), and the occasional kimono-clad woman pressed by the millions through the subterranean railway stations every day. To me, this subway was nothing more than a gauntlet of ticket wickets, subway doors, and drunk businessmen that had to be run three or four times a week. For others, this maze is home.

By day, these invisible men work construction sites and sweep streets. Their pitiful salaries will not pay for rent anywhere in the richest city in the world. So, when the last trains have departed, they take over the abandoned passages and plazas. Living in cardboard boxes, they are utterly ignored by everyone except the groups of foreigners who go out to distribute rice to them. The morning I first joined my high school's National Honor Society on a 4 AM "rice patrol," we met over a hundred men waiting patiently for us just one level below where dozens of neon-clad skiers were waiting for early trains to the resorts. From then on, every time I came to Shinjuku station on the way to a debate tournament or back from a dinner with friends, I saw, in the empty spaces behind stairs and along narrow hallways, visions of the men who disappeared during the day but who would reclaim the station as their own at night.

The year after my first rice patrol, I had the chance to organize the next year's patrols. Even friends of mine who had spent their whole lives in Tokyo were moved by the experience. It was the one time I, the relative Tokyo "Newbie," had the chance to reveal something new to the jaded old-timers. While working with the rice-patrol was a wonderful experience, having the chance to share that experience with others was even better.

We all become parts of the lives we meet. The excitement of my summer school students working on their Internet projects right through the class break, the joy of a stroke victim I had worked with for weeks as she suddenly regained full movement, or the relief of a friend sharing concerns about family and classes with me, has always thrilled me. Having a life of experiences like this is a reward in and of itself. But even greater is to share those experiences with others.

There are many possible purposes for our lives. Some live life for pleasure. Others to amass fortunes or dominion over other men. I live to serve. Non sibi, not for self, is the motto of Andover academy, and mine too. For as long as I can remember, I have wanted to help those who need help the most. One of two reasons I want to make serving others my life's purpose is because I enjoy helping others, as discussed above.

There is a second, complementary reason. From those who much is given, much is expected. This idea was impressed on me by my ninth-grade chemistry teacher, Mr. DiGaitano. That was his rallying cry, his mantra. That was what he exhorted even as we limped into early morning class, even as we fell asleep during marathon review sessions for the state chemistry exams. If we did our best, he believed, we had the chance to do well in Chemistry and in life; he'd be damned before he let us get away with anything less. He gave everything he had to us through his animated lecture style, his over-the-top chemistry experiments, his willingness to listen to us at all times. He, by his example, inspired us to give our best.

Years later, I discovered the origin of his battle cry, and its origins give his words added meaning. From Luke 12:48 from the New International Version Bible:

From everyone who has been given much, much will be demanded; and from the one who has been entrusted with much, much more will be asked.

To me, this is not an arbitrary command. It's a perfectly valid point. So many people in this world have been denied basic human needs. Billions starve or die of disease. Hundreds of thousands are killed in war or live in dictatorships. Thousands never had the chance to get an education, or the love and support of family. For some mysterious reason, God gave me all of the above.

I sincerely believe that I am one of the most fortunate people who have ever lived. What little family history survived the Chinese Revolution stresses this fact. My father's family spent three years fleeing the slaughter of the Communist sweep across China. My mother's family survived waves of economic disaster and political chaos in Taiwan. My parents worked like slaves in school to qualify for permission to emigrate to the United States as scholars, and then worked harder to assure a future for my brother and me. I was born free and healthy. I grew up in a loving family and a decent school district. I had the opportunity to choose any profession, any major, that I possibly wanted.

For almost a century of struggle, God had watched and protected my family. For almost two decades, my parents have labored to protect my brother and me. So much had been given to me that was denied others for reasons I will never understand. I feel I have a duty to use the talents and skills I have been fortunate enough to obtain to make the lives of others better.

So, in the final analysis, what calls us on? What thing greater that material comfort and security draws us forth? Ulysses was called forth by the camaraderie of battle and the thrill of exploration. I believe many of us are called forth by the joys of volunteering, the desire to serve, and the responsibility to return something to a world that has been kind to us.

Ulysses quests for something greater than himself. His son, Telemachus, choose not to join Ulysses on his last journey. Telemachus has chosen to serve the people of their kingdom, a quest that is different, but no less noble, than Ulysses' journey. There are many whose life's goals are different than mine, and it would be presumptuous of me to claim my quest is superior to all others.

Even among those who have chosen to spend their lives serving others, obviously not all choose to become doctors. Many become teachers, preachers, or counselors. I have laid out reasons why I and so many others have chosen to dedicate our lives to service. So why do I and so many others want to serve as doctors?

One chemistry teacher I once had pointed out that I could help improve the quality of life of many more people by becoming a civil engineer and helping build sewer and clean water systems for third-world nations. For me, that argument is flawed. While building a clean-water system for a city would indeed help millions at a time, the obstacles to building those systems are economic and political rather than professional. Any group of skilled engineers - or even a well programmed computer - could design an optimal water system; it is a matter of the government having the political will to build it. Indeed, it's not really the engineer who brings help to the people - it's the banker or the mayor who makes construction of that system possible. I would rather spend my life fighting a battle where individuals can make a difference on a personal level.

So, others point out, if you want to help people on a personal level, why not become a teacher, a counselor, or a priest? I believe that all three are important and honorable jobs. However, there is nothing that prevents a physician from being a teacher, a counselor, and a missionary as well as a healer. In fact, I believe that the best physicians are all four. It's not that being a physician is somehow a "more noble" or "greater" profession than any other. However, even the most compassionate social worker can't reattach a severed leg, transplant a liver, or remove a tumor from the center of the brain. Only the physician gains the specialized skills needed to fight death, the greatest of all human enemies.

Not only can a good physician be both healer and friend, but today, a good physician must be an advocate as well. It is no longer enough merely to treat a patient's physical and spiritual maladies; it is necessary to obtain the financial resources that make that treatment possible. A ear to listen and a shoulder to cry on are free. Chemotherapy and CAT-scans, operating rooms and orthopedic implants cost money. Lots of it. The skills gained by the physician also confer the authority to fight for patients before the insurance review boards and the corporate board rooms, to argue, wheedle, twist and tweak a corrupt and collapsing system for the pennies needed to save each patient. Today, the altruism of physicians is meeting the profit-seeking greed of many insurance companies head on, and lives hang in the balance.

The advent of battles between bureaucrats and physicians is part of a wider struggle for the future of medicine. Today's medicine has introduced new questions. Who gets care? Who pays for it? Who decides? And who decides who decides? Decisions about health care reform, physician-assisted suicide, genetic testing and engineering, and other national issues are not made only by bureaucrats in skyscrapers and politicians in marble halls. The actions by the doctors and nurses in the trenches - individual acts of resistance and resourcefulness, group lobbying and political actions - will determine both what rules are created and what rules are enforced. The next ten years will shape the future of medicine and the future of the society that depends on it.

While the uncertainty and the struggle have made the medical field much more grueling for its practitioners, the opportunity to shape the future makes this the most exciting time in this century - perhaps ever - to join the battle, to become a physician. For every unscheduled marathon emergency-room surgery, there is a life at stake. For every late-night session counseling the family of a terminally ill patient, there is a life at stake. For every battle against insurance company bean-counters and bureaucrats, there is a life at stake. The battle is so hard - and so rewarding - precisely because so much is at stake.

Not all who dedicate their lives to others serve as physicians. There is absolutely nothing dishonorable or lesser about the many other professions that serve others. They are simply different. Nothing makes Ulysses' chosen struggle morally or ethically superior to Telemachus'. It is simply different. Whether or not we choose to serve is a choice. How and where we serve is a choice. There are no right or wrong choices; there are only the choices we each make alone. For me, I have always wanted to try to help those who needed help the most, and I believe that I can best do that as a physician.

So, why do we do this? Why are we pre-meds willing to give up so much to become physicians? Because, like the salmon, like Ulysses, eventually we all die. It is what we live for that counts. For those who have chosen medicine as their life's work, the struggle of being pre-med is a fair price for the chance to serve as healers, as counselors, as advocates - as physicians. Despite our complaints and protests, would we, if given the chance, choose to do anything else with our lives? The answer is no.

I do not know if I have what it takes to succeed as a physician. I do not know if I have the skills or the courage to complete the journey that I have chosen. But, like Ulysses, I know I am going to give my chosen journey every ounce of strength that I have. Perhaps Tennyson put it best: