Medical Training Culture — A Quick Reply

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This article is in reply to the well articulated piece Tulane MD/PhD candidate (Stiletto + Stethoscopes): http://stilettosplusstethoscopes.com/2015/03/12/loneliness-is-the-poverty-of-self-solitude-is-the-richness-of-self-may-sarton/. She made excellent points, so be sure to check it out (it’s likely better than this article).

My response to their article isn’t as polished, I’d even say my response is downright clumsy. But, for what it lacks in style and refinement hopefully you’ll  find will be brimming with honesty. And really, the purpose of this piece is merely to keep the conversation going. You my find this piece to be more acerbic and pessimistic then my usual writing, but this dialogue needs to happen. The point of this piece isn’t to scare premeds out of medical school applications, instead it’s to normalize the feelings that are politically incorrect to ever mention in front of your student body.

Understandably, human gross anatomy and the first year of medical school is a formative and seminal event for every physician in training.

But in all seriousness, how is skinning, lopping of their breast, meticulously scrapping out their fat, bisecting their genitals and dismembering a human not supposed to be a traumatizing experience in medical school? For the love of Pete, I’ve held a severed leg in my hands.

Gross Anatomy is and starting medical school is hard, and not just because of the amount of material.

Neither the less, most people get through it. I succeeded by distracting myself with the awe and appreciation that someone would give up their body for medicine as our first ‘patient’ — so that we can be a physicians. I believe an important bond is formed between our first patient and ourselves. This is mostly a bond of responsibility. Responsibility turns into guilt when we feel we didn’t hold up our end of the bargain. I mean imagine the guilt associated with knowing that someone (and their family) gave their body to you and you feel you didn’t give it your all, whether that be because of class load (30+ equivalent undergraduate units, a considerable chunk of it not being all that clinically relevant but extremely easy to test), hopefully you’re passing all of your classes, burn out and depression, or personal reasons such as ‘untimely’ deaths or illnesses of closed loved ones. Some just feel bad for “not enjoying ” like everyone else seemingly are. I’ve seen students try to express themselves, hoping to find some sympathy from their colleagues only to be shutdown for not being “into it enough“, albeit an inadvertent discouragement.  This is the first layer of guilt some of us experience, wondering if you’re worthy of what we’re tasked to do.

There was one person who I believe dealt with it in a healthy way, crying from time to time. I respected them a lot for this, for their strength. Admittedly, I learned of murmurs of others who found this person to be “weird” or “overly emotional”.

You’ll quickly learn how to stuff your emotions into the closet — hopefully, you learn when to open that closet as well.

For my first semester of medical school I struggled with the moral dilemma of visiting a recently diagnosed cousin with terminal cancer. I need not defend my actions or intentions, I selfishly decided to not travel during my midterms as I knew without a doubt she’d likely die in the interim. I find myself on the right side of history but on the wrong in morality — for this I can admit my hypocrisy as I’d never fault another student for making the same decision to stay and take their exams. Everyone, including my terminal and now deceased cousin, comforted me by telling me to stay and thus transgression was forgiven by others. It’s no secret that medical students and physicians in training miss a plethora of things: deaths, funerals, wakes, and births. I suppose the part most people don’t know is how quickly these things most be given up or put on hold, at times I wonder what things I’ll later miss or the people who think I forgot about them in their time of need.

Not everyone is a medical zombie, not everyone tries to wear a suit of armor to hide their feelings. I can’t recount the number of times people who I assumed “had it all together” confided to me nearly in tears about the stress, anxiety, and feelings of inadequacy. There’s been even a rare conversation or two when students have admitted to me about thoughts of taking their lives, or as the called it sometimes “I just want to off myself”, during the first semester but not wanting to be outed as “depressed” or lose respect. Some dropped out (once you’ve made up your mind it’s a wise decision), while others have (bravely) taken psychological medical leave with intent to return when they’re ready. Fortunately, my program recognizes mental health as a health concern not a competency one, sadly; I can’t say this is a universal policy among programs or our potential residency spots. It’s a sad day when medical students and physicians can have guilt about their own mental health status, but with uncertainty of being discriminated against we should expect physicians in training to not seek help when they need to.

You’ll quickly learn how tied your hands will be later.

At the clinic I quickly learned that a knowledgable provider prescriptions’ in no way guarantees or even implies that the patient will receive said treatment or medication. Having insurance doesn’t mean coverage. I recall one conversation a physician had with a long time patient:

Doctor: actually, there is a medicine has a 95% cure rate for your condition

Patient: OH MY GOD SIGN ME UP!

Doctor: the only problem is it costs too much and you’re insurance won’t cover it, unless you get more sick. But, then if you’re too sick they won’t cover it either… It’s typically denied, but I’ll try it anyways.

Patient: …wow, so there’s a cure and I can’t get it?….

Doctor (to me): better get ready for this kind of stuff.

It’s a bitter pill to swallow that all we learn about drugs and diseases can be overturned by a swift “denied” stamp by a clerk. However, at the end of the day a person need be blamed, and that clerk will be no where to be found. Remember not the best treatment, but the covered treatment — even if it’s an inferior treatment. And let’s face it, when it comes to billing people can incorrectly assume that doctors are behind a scheme to over bill (sometimes with deadly results) — this is despite the gradual shift away from fee-per-service and into capitation. It looks like, for now, we’ll just have to enjoy the orphaned guilt not taken up by billing. When I sit in the bus towards I hear patients lament at how incompetent and irresponsible doctors are, including blaming doctors for lobby wait times. Fortunately, I haven’t deluded myself into thinking physicians are universally respected. Clearly, when people prefer Jennifer McCartney about vaccinations over their physician something is misplaced.

Never the less, I’m not disheartened by the realities of medicine, or the culture. Though not at the pace I’d like, I see the culture changing as we speak. In fact, I feel more empowered as I slowly gain a grasp of what “we signed up for” and I’d rather be part of the fight then on the sidelines — let’s hope it stays that way. There are tone of positive things about medicine, you only need to check the rest of my blog for upbeat posts. But really, if you’re going to marry medicine you better be willing to accept the good and the ugly or you’re in for a rude awakening.

And, I’d be irresponsible if I didn’t level with you.

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