Monday, June 28, 2010


If you want to understand medical doctors better, you need to know that they constitute a tribe--with its own traditions, customs, language, and perspectives.

We physicians call our professional education “training.” That's an appropriate term, because in addition to learning medicine we get steadily inducted into the tribe. The tribal curriculum is implicit, yet almost any physician anywhere in the United States will agree that his or her medical education was characterized by a hefty degree of
  • Rigid hierarchy. Freshman medical students occupy a niche just below mollusks. Sophomores and juniors are noticed, but mainly as nuisances, like rodents. Seniors find that the summit they’ve attained is no higher than dirt on the shoes of interns, who in turn are nameless drudges to resident physicians. And so on up to the pyramid’s apex, the chair of the department, who glows with success while fretting about the associate professors clawing at his or her ankles.

Within such a system, one learns one’s exact place through the principle that abuse flows downhill. As a senior student, I saw a resident loudly upbraid my intern. An hour later, that same intern berated me for a minor omission. And that evening, I’m sorry to say, I joked with my roommates about how dirt-ignorant one of my patients was.

  • Inadequacy. There’s far more for doctors-in-training to know than anyone can possibly learn; even worse, what was so yesterday ain’t necessarily so today. Little wonder students continually feel deficient. They compensate with “roundsmanship,” casually citing obscure medical facts that send their classmates into seizures of self-doubt. Years of such defensiveness tend to breed feigned confidence just a tick short of arrogance.

  • Overwork and sleep deprivation. Ripping along on caffeine all night to prepare for next morning’s freshman physiology exam is grueling, but it’s only practice for later training, when the junior student sees patients around the clock. In addition, sleeplessness dulls the edge of intellect, leaving the student ready, even longing, to accept instruction unquestioningly.

The overwork issue blossoms in American media every ten years, like a cicada cycle. Learning that a surgical resident about to operate on us hasn’t slept since last Whitsuntide, we jump off the gurney, write letters to editors, and call for Congressional hearings. Headlines blare outrage for a week, and then the issue burrows underground again for a decade. That this pattern has persisted so long with so little reform might suggest to a visiting anthropologist that we regard healing as a zero-sum transfusion, the patient’s improvement being roughly equivalent to the healer’s depletion.

In any case, overwork is likely to remain mainstream healthcare’s modus operandi indefinitely. I’ve heard from more than one medical educator, for example, that many resident physicians view any limits on their work week as insults to their overachievement ethic. (Overwork isn’t limited to doctors, by the way: it’s not uncommon for relatives of sick people to work themselves into sickness.)

  • No free time. Do it now, “stat,” and when you’re finished, draw that blood down in 121. Thinking, wondering, and chatting with patients are extraneous to the work at hand. The relentless activity obsession is rewarded later, in practice, when third parties pay doctors for physical procedures, never for simply sitting and listening to their patients.

  • Unhesitating dedication. When medical students’ personal and family needs compete with training obligations, they’re sternly reminded that a physician’s devotion to duty must be virtually monastic (an apt term, as non-medical people are often referred to as “lay.”) By their third year, students know that a meaningful personal life must remain on the back burner indefinitely. One of my classmates, an orthodox Jew, said he couldn’t be available to work on Saturdays, the Sabbath. The dean had heard that one before. He handed the student a photocopy from his files, a letter he’d secured years before from a rabbi stating that “saving lives” justified working on the Sabbath.

  • Social isolation. Medical students spend their off-time either studying hermetically or restricting themselves to the tight circle of their classmates. During years cloistered together, away from worldly competing views, they succumb to pressures toward clinical detachment while their skills in plain old personal relations atrophy.

Last year I asked a young pathologist about his work. He told me one of its advantages was his ongoing patient contact.

I took heart. “That’s unusual,” I said. “Most pathologists are notorious medical homebodies. How exactly do you contact patients?”

He said, “Well, sometimes I’ll examine a tissue slide and it doesn’t quite add up. But when I go to the ward and read the patient’s chart, things almost always fall into place.”

I was puzzled. “And you see the patients, then?”

Now he looked puzzled. “See the patients? Why would I do that? All I need is the chart.”

If my list of implicit curricula—hierarchy, inadequacy, sleep deprivation, enforced busyness, hyperdedication and isolation—sounds familiar, it’s probably because it recalls the “brainwashing” techniques that cults and totalitarian governments use to “re-educate” captive audiences. Immersed for years in this ambiance, it’s a rare medical student whose personality doesn’t accommodate to it. The physicians I know who truly are skilled in personal contact aren’t that way because of their training, but despite it.

A few years ago I attended a medical conference on quacks and cults. One of the presenters, a professor of internal medicine, described the features of a cult. They matched my list. I raised my hand and suggested that medical training might actually constitute a cult. Obviously he’d considered this before. Smiling, he said, “Well, what you say does pertain to surgical training.”

That got a laugh from everyone, and partly, I suspect, because his gentle refutation was actually an admission. We docs are a tribe, exclusive and internally consistent, and we’re evidently satisfied with it.

1 comment:

  1. Ditto for nursing school, but to a lesser degree...

    I remember some very inspiring voices in the night in nursing school, who assured me that the brutality and harshness and outright torture we experienced at the hands of our professors was not the total truth, and that all the stuff they tried to put the fear of God into us about was only a small fraction of the picture...and the best nurses told me that after a year or two of practice, they slowly began to realize that all the skills and things they learned in nursing school that they prided themselves on, was not actually what nursing was all was really about the people and the connections they made with them...

    I wish I could find some of them to thank them, but who knows where they are now, and I can't even remember their names....

    Nurses, ironically, are _allowed_ to achieve more balance in our lives...we are afforded, for the most part in hospitals, far shorter work-weeks than doctors...we are predominantly female, so it is assumed we are the primary caregivers for our families, too, and our work conditions tend to reflect that reality...

    I tend to be only dimly aware of all the pressures the doctors I interact with face...but the sheer daunting magnitude of their patient loads compared to ours makes many of us nurses loathe to "interrupt" rounds, or whatever, unless it is truly life-threatening...we try to prioritize requests to avoid having our heads bitten off, even when it IS life and death...
    This post really explains a lot, and makes a forceful argument...and yes, I have witnessed the cycles of outrage and congressional hearings...! alas, and nothing changes....