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Amputated Pride


The New Physician May-June 2000
To err is human, we are constantly told—and it’s acceptable at least until one enters medical school. Suddenly students who have spent most, if not all, of their lives as overachievers find themselves in an intensely competitive, brutally demanding environment where tolerance for mistakes hovers right around zero.

One second-year medical student describes her first year as “like trying to take a drink of water from a fire hydrant.” The grueling academic and clinical hurdles medical students must clear offer only a hint of the pressure they will feel during their residencies and afterward, when the slightest slip could mean a patient’s life.

Usually, the potential hazards of the overload principle governing medical education become apparent long before a student sees his or her first patient. This is, as most medical students will readily admit, probably a good thing. After all, a medication mix-up or chart bait-and-switch, as the Institute of Medicine so ominously reminded us last year, can result in preventable patient deaths. Confusion in the classroom, by contrast, is potentially fatal only to a student’s ego.

Some physicians say that embarrassment—public humiliation—may be a necessary evil for students to experience as they mature and develop into well-rounded physicians. Other doctors condemn the culture of peer scrutiny as cruel and inhumane to both doctor and patient. Students, for the most part, just want to survive the semester. But whatever self-affirming existential truths may be gleaned from debate over the role of humility in the art of healing, at least two things are clear: 1) Everyone who has ever gone through medical school has at one point or another wanted to become invisible. 2) The scenarios resulting in 1) are usually damn funny.

Class I—The Temporal Lapse -- Because many medical students are familiar with the concepts of “sleep” and “nutrition” in the same context as they are familiar with “borborygmi” and “congenital dacryostenosis,” they may be forgiven for occasionally having a fluid and highly subjective sense of time.

Aga Lewelt, a second-year medical student at the University of Virginia, remembers arriving at her weekly “Introduction to Clinical Medicine” tutorial group session to find only one seat open. The seat happened to be between her group leader (the dean of student affairs) and one of his close friends, an esteemed visiting scholar.

As Lewelt took her seat, the dean asked the group what seemed to be a fairly specific clinical question given that she thought the group members had yet to receive their six-page case-review packets—each containing a patient history, physical exam summary and lab results, to be reviewed in strict sequence. An ambitious student, Lewelt threw an answer into the ring anyway. Seven blank stares greeted her in response.

“I look around, and I see everyone’s packet is open to page four,” Lewelt says. “And I’m like, ‘Oh, my God, everybody’s cheating! You can’t look at the lab results before you’ve gone over the physical exam!’ So then the dean hands me mine, and I think, ‘I’m not going to open it yet; I’m not going to cheat just because everyone else is.’ Then, after like, five seconds, the realization just came: This thing lasts two hours, and I was exactly one hour late… I felt weak. I was like, ‘Please don’t let this be happening!’” Noting that the dean is “the guy who writes our letters,” Lewelt strongly recommends avoiding causing one’s dean, to say nothing of one’s self, embarrassment in front of a colleague whenever possible.

Class II—Our Bodies, Our Selves -- No creature has ever been as obsessed or uncomfortable with its own physical nature as man. We treat biological necessities, such as sweating or going to the bathroom, with revulsion. Medical students, naturally, learn to either rise above such foolish impulses or at least bury them beneath a veneer of professionalism.

All that aside, gross is still gross. Just ask Rahul Bhat, a second-year medical student at Boston University (BU), who could have happily realized his dreams and aspirations in medicine without ever tasting human fat. Unfortunately, his gross anatomy lab partner, Charlie Bergstrom, also a BU second-year student, was something of a novice in the use of a scalpel. Bergstrom’s first attempt to cut open a cadaver launched a piece of fatty tissue across the table, where it landed on Bhat’s lip.

“He couldn’t wipe it off because he had his [dirty] gloves on,” Bergstrom says. “He couldn’t ask for help, because it was on his lip—it would have gone into his mouth.” Bhat waved his arms and made non-verbal sounds until somebody finally came to his aid with a paper towel.

Class III—Absence of Malice -- Like anyone else, physicians can do stupid things when they’re tired or when they simply don’t pay attention. Stories like the one about the third-year student who, while serving an ob–gyn rotation, accidentally put cells from a Pap smear into her attending physician’s coffee may sound like a gag rejected as too vile even for the next “Austin Powers” sequel—but they happen, and the agents of such bizarre acts usually survive their shame.

Dr. Allen Neims, a professor of pharmacology and therapeutics at the University of Florida College of Medicine, says he still remembers the first day of his ob–gyn rotation during his third year at The Johns Hopkins University School of Medicine. Neims had been up all the previous night caring for a woman in labor—his first clinical all-nighter—and was exhausted.

Neims recalls collecting a urine sample from his patient. But as he walked out of the room to conduct the urinalysis, the chief nurse—a woman who “chewed up medical students and spit them back out,” Neims remembers—asked him where he was going. When he answered her, she told him to wait a moment and returned with the entire ob–gyn clinic’s nursing staff. She wanted to show them the medical student who was going to attempt to perform a urinalysis on a bowl filled with fluorescent yellow hand soap. Neims sheepishly returned to his patient to collect the right container.

Class IV—And All My Friends Were There -- Some cheek-reddening episodes students experience are not unique to the setting of medical school, but have a sentimental resonance as a result of the strong bonds that develop among medical school classmates—not that you need to know someone intimately to enjoy a laugh at their expense.

Alex Gonzalez, a second-year medical student at the University of Miami, says his most embarrassing moment in medical school came during his tenure as class president his first year. On Gonzalez’s birthday, the class treasurer reported to class dressed as Marilyn Monroe. Before the lecture began (but after his 100-plus classmates had arrived), Ms. Monroe sat on Gonzalez’s lap and sang “Happy Birthday” to—of course—Mr. President.

Smile—This too Shall Pass -- Experiences such as these are fun to discuss, but does the act of being embarrassed among one’s peers make one a better physician? As with so much in medicine and in life, it depends on whom you ask.

The University of Florida’s Neims says that while humility and humbleness are qualities to which doctors should aspire, they are not necessarily the products of embarrassment. Unless students can accept and learn from their failures, embarrassment may actually breed anger and arrogance. But how one responds to embarrassment can be a strong indicator of character.

“If you can live through an embarrassing moment and smile at yourself, you can smile at life,” Neims says. Accepting one’s limitations and learning from one’s mistakes are crucial to surviving medical school—and later on, to communicating effectively with patients, he says.

Dr. Bhaswati Bhattacharya, a public health and preventive medicine specialist at the Mount Sinai School of Medicine, agrees, but argues that “the militaristic system of training doctors” offers medical students little opportunity to learn from their mistakes. Medical educators’, and even one’s fellow students’ neglect to acknowledge the value of failure in the learning process “propagates a system of emotional violence,” Bhattacharya says.

“Some people like the [current] pejorative, slap-in-the-face kind of environment because that helps them learn,” she says. “But medicine is not a fraternity anymore…. Medical students these days are at different levels of maturity.”

Bhattacharya still bristles at a few embarrassing memories from her school days. She remembers that in her second year, her class was directed to learn only the generic names of medications. But when her third-year rotations arrived, and hospital staff used the drugs’ commercial names, Bhattacharya felt humiliated for having to ask which drug was which. “They were like, ‘I can’t believe you didn’t know that drug name,’” Bhattacharya says. She says that kind of condescension is characteristic of medical education.

Regardless of what could be done to make medical education a less grueling environment, the prospect of ever removing one-upmanship and competition from a field as selective as medicine seems unlikely. And while no one enjoys being made to feel ashamed of their limitations, some students, as Neims suggests, have learned to accept the occasional bout of embarrassment as part of the broader experience.

Miami’s Gonzalez, for one, has learned to counter the occasional derisive laughs of others by keeping his own sense of humor intact. “Coming to medical school was simply the process of extending into my professional life the embarrassment I felt every day in my personal life,” Gonzalez jokingly says.

The smile is still on his face when the more reflective summation comes. “Seriously though,” he says, “when you get to medical school, you look at who is around you and you realize, ‘I’m not such hot [stuff] anymore.’ And that’s OK.”
Chris Klimek is a former associate editor of The New Physician.