To be disillusioned is to be moved closer to reality. To be disillusioned is also to suffer a devastating blow to motivation, purpose, courage, resiliency, inspiration. Young people in our society continue to be drawn to medicine by the vision of caring deeply for patients, the vision of making a difference in patients’ lives. At various points across the continuum of medical education, they realize the vision that drew them to medicine is, far more often than not, an illusion. For many, the humanistic language they used just a few years before in their personal statements for medical school feels hollow, embarrassingly naive, when recast in their personal statements for residency.
Anxious medical students cope with their disillusionment behind an unstated code of silence. Weary residents wrestle with decisions to place higher priority on much-needed sleep than on actions and experiences that would benefit patients. Insecure young physicians stumble through their first few years after residency without mentors to hold them accountable as they sort out their professional values and priorities.
A junior pre-med student, during a visit with the community health center where I work, disclosed -- “I have shadowed a number of physicians – private and academic – this past year and did not find one physician I would like to be around.”
A frustrated medical student, near the end of his first year, disclosed – “We had the ‘keep your balance, don’t lose your relationships’ orientation talk from the dean on Day One. And an ethicist reminded us the same day to ‘nurture your interior life’. Day Two blew by all that. After the first round of tests, reality set in. Getting decent grades means 80-100 hours of study every week. What’s left for relationships? or for my ‘interior life’? The grades for my first set of tests reassured me. I can do this. But at what price? I guess the dean and the ethicist will recycle their platitudes to the next class of new students. Where is the dean? Where are the ethicists? Obviously not near enough to us to speak with understanding and integrity. I feel betrayed.”
A confused third-year medical student – considered by the faculty to be one of the top students in her class – admitted soon after her first clinical rotation – “I am excited about finally being in the clinical setting. I want to help patients. I want to contribute to the team. I understand I need to make my upper level look good. And yes, I want to impress the residents and attendings. But now I feel very uncertain. Residents and attendings broke bluntly into my case presentations. It’s demeaning to be told -- ‘We don’t have time for a 3rd-year medical student history and physical’-- and then to be ignored. The one thing I thought I knew how to do was a ‘history and physical’. I am afraid of failing, of appearing weak.”
A shaken student near the end of his third year, in response to questions about the way he selects rotations and thinks about possible residency programs, realized – “It’s all about balancing residency program status with personal convenience. I am in the rural-track program of my medical school because I began with the intent to practice in an underserved area. But my fellow rural-track students and I hardly ever talk about that goal when we discuss rotations and the residency programs we are considering.”
A tearful fourth-year medical student, during her interview for a residency program, revealed – “I majored in English Literature. But when I sat down to write my personal statement for the residency application, I discovered I had lost the skills to think in narrative style or to write an essay.”
A second-year Ob/Gyn resident, during a lunch conversation, admitted -- “By the third year of medical school, I realized that being a physician is not what I had envisioned. Being with patients and making a difference in their lives 90% of the time would be great. Even 70%. But 40%? or less? I feel stuck. What else can I do? It is hard to quit after having invested so many years. I am not in medicine for the money. There are much faster and easier ways to that goal. My college friends are making shit buckets full of money while I am sacrificing my 20s and amassing an enormous debt. I am frightened by the ways I have changed. Fatigue has darkened my mood and shaken my plans. My family/friends do not understand how tired I am. Will these changes reverse after residency?”
A young physician, three years out from residency, explained -- “The audience in residency is your attending physician. You tend to adopt his/her approach. If you take your own approach, you risk getting into trouble. So you put personal responsibility on a back burner. Your career rides on the attending’s interpretation and your upper level’s interpretation of your performance. Residents – especially interns – implement the decisions of those above them. They must move quickly. They know their medical analyses will be quizzed. They have little time to think about anything else. Every year that such reflection is suppressed, the harder it is to recover. Many residents take the position – ‘When I get out, I won’t do it that way’. The danger in taking a ‘later’ attitude is that you tend to become what you do. Many days slip quickly into a downward spiral. You fall behind due to patient volume and the inability to anticipate or control the complexity presented by patients. ‘Getting the work done’ takes over. Addressing the ‘chief complaint’ without falling further behind severely restricts attention to deeper issues in the patient’s story. This cycle eats away at the joy of what you are doing.”
A physician in his late 30s, a couple of years past his decision to leave the practice of medicine, remembered --
“I made undergraduate course selections for requirements other than pre-med courses based on whether a course or instructor would make it easier to get into medical school. The humanities were downplayed/downgraded at my undergraduate school. Pre-med students were perceived and thought of themselves as the toughest among all the students in science programs. The sneering about the humanities was severe. I did not realize then that to let the mental habits characteristic of the humanities atrophy is to let a crucial part of the self die. Yet students, residents, academic physicians, and practicing physicians who place value on these traits run the serious risk of being perceived as not being fully committed to medicine. Medical school and then residency are meat grinders that spit you out on the other side. You are pushed through. There is little or no opportunity to pause and assess. There is hardly any occasion to ask, ‘Why am I doing this? Is this what I want to do? Is this what I ought to do?’ It is ironic that during the years when you need to be most reflective, you do not have the tools, the time, or the energy.”
A 43-year-old physician, with fourteen years experience as lead physician for a non-profit community health center in a poverty-burdened Appalachia un(der)service area, concluded --
“Medical school and residency are not educating experiences. You are not taught how to think. You do not engage ideas. You memorize information and learn to make differential diagnoses. There is little historical perspective. Medicine is not integrated into larger and related spheres of thought. Becoming a physician is analogous to a trade school experience. Little attention is given to what it means to be a ‘professional’.”
A physician in her late-40s, after reviewing the manuscript for this presentation, reflected – “I remember quite clearly my first day in medical school. The dean did not mince his words. ‘Medicine must be your husband, your wife, your children, your family, your life. If you can’t make this commitment, get out now.’ I fought to keep hold of the grand ideas that brought me into medicine. I fought against the dean’s angle on medicine. And twenty-five years later, I am disillusioned about my profession, burned out, cynical. The medical school, residency, and practice settings have worn me down.”
Such grim dispositions are too widespread to be ignored in discussions of ‘ethics’, ‘the art of medicine’, ‘professional competency’, ‘integrity’.
Anxious medical students cope with their disillusionment behind an unstated code of silence. Weary residents wrestle with decisions to place higher priority on much-needed sleep than on actions and experiences that would benefit patients. Insecure young physicians stumble through their first few years after residency without mentors to hold them accountable as they sort out their professional values and priorities.
A junior pre-med student, during a visit with the community health center where I work, disclosed -- “I have shadowed a number of physicians – private and academic – this past year and did not find one physician I would like to be around.”
A frustrated medical student, near the end of his first year, disclosed – “We had the ‘keep your balance, don’t lose your relationships’ orientation talk from the dean on Day One. And an ethicist reminded us the same day to ‘nurture your interior life’. Day Two blew by all that. After the first round of tests, reality set in. Getting decent grades means 80-100 hours of study every week. What’s left for relationships? or for my ‘interior life’? The grades for my first set of tests reassured me. I can do this. But at what price? I guess the dean and the ethicist will recycle their platitudes to the next class of new students. Where is the dean? Where are the ethicists? Obviously not near enough to us to speak with understanding and integrity. I feel betrayed.”
A confused third-year medical student – considered by the faculty to be one of the top students in her class – admitted soon after her first clinical rotation – “I am excited about finally being in the clinical setting. I want to help patients. I want to contribute to the team. I understand I need to make my upper level look good. And yes, I want to impress the residents and attendings. But now I feel very uncertain. Residents and attendings broke bluntly into my case presentations. It’s demeaning to be told -- ‘We don’t have time for a 3rd-year medical student history and physical’-- and then to be ignored. The one thing I thought I knew how to do was a ‘history and physical’. I am afraid of failing, of appearing weak.”
A shaken student near the end of his third year, in response to questions about the way he selects rotations and thinks about possible residency programs, realized – “It’s all about balancing residency program status with personal convenience. I am in the rural-track program of my medical school because I began with the intent to practice in an underserved area. But my fellow rural-track students and I hardly ever talk about that goal when we discuss rotations and the residency programs we are considering.”
A tearful fourth-year medical student, during her interview for a residency program, revealed – “I majored in English Literature. But when I sat down to write my personal statement for the residency application, I discovered I had lost the skills to think in narrative style or to write an essay.”
A second-year Ob/Gyn resident, during a lunch conversation, admitted -- “By the third year of medical school, I realized that being a physician is not what I had envisioned. Being with patients and making a difference in their lives 90% of the time would be great. Even 70%. But 40%? or less? I feel stuck. What else can I do? It is hard to quit after having invested so many years. I am not in medicine for the money. There are much faster and easier ways to that goal. My college friends are making shit buckets full of money while I am sacrificing my 20s and amassing an enormous debt. I am frightened by the ways I have changed. Fatigue has darkened my mood and shaken my plans. My family/friends do not understand how tired I am. Will these changes reverse after residency?”
A young physician, three years out from residency, explained -- “The audience in residency is your attending physician. You tend to adopt his/her approach. If you take your own approach, you risk getting into trouble. So you put personal responsibility on a back burner. Your career rides on the attending’s interpretation and your upper level’s interpretation of your performance. Residents – especially interns – implement the decisions of those above them. They must move quickly. They know their medical analyses will be quizzed. They have little time to think about anything else. Every year that such reflection is suppressed, the harder it is to recover. Many residents take the position – ‘When I get out, I won’t do it that way’. The danger in taking a ‘later’ attitude is that you tend to become what you do. Many days slip quickly into a downward spiral. You fall behind due to patient volume and the inability to anticipate or control the complexity presented by patients. ‘Getting the work done’ takes over. Addressing the ‘chief complaint’ without falling further behind severely restricts attention to deeper issues in the patient’s story. This cycle eats away at the joy of what you are doing.”
A physician in his late 30s, a couple of years past his decision to leave the practice of medicine, remembered --
“I made undergraduate course selections for requirements other than pre-med courses based on whether a course or instructor would make it easier to get into medical school. The humanities were downplayed/downgraded at my undergraduate school. Pre-med students were perceived and thought of themselves as the toughest among all the students in science programs. The sneering about the humanities was severe. I did not realize then that to let the mental habits characteristic of the humanities atrophy is to let a crucial part of the self die. Yet students, residents, academic physicians, and practicing physicians who place value on these traits run the serious risk of being perceived as not being fully committed to medicine. Medical school and then residency are meat grinders that spit you out on the other side. You are pushed through. There is little or no opportunity to pause and assess. There is hardly any occasion to ask, ‘Why am I doing this? Is this what I want to do? Is this what I ought to do?’ It is ironic that during the years when you need to be most reflective, you do not have the tools, the time, or the energy.”
A 43-year-old physician, with fourteen years experience as lead physician for a non-profit community health center in a poverty-burdened Appalachia un(der)service area, concluded --
“Medical school and residency are not educating experiences. You are not taught how to think. You do not engage ideas. You memorize information and learn to make differential diagnoses. There is little historical perspective. Medicine is not integrated into larger and related spheres of thought. Becoming a physician is analogous to a trade school experience. Little attention is given to what it means to be a ‘professional’.”
A physician in her late-40s, after reviewing the manuscript for this presentation, reflected – “I remember quite clearly my first day in medical school. The dean did not mince his words. ‘Medicine must be your husband, your wife, your children, your family, your life. If you can’t make this commitment, get out now.’ I fought to keep hold of the grand ideas that brought me into medicine. I fought against the dean’s angle on medicine. And twenty-five years later, I am disillusioned about my profession, burned out, cynical. The medical school, residency, and practice settings have worn me down.”
Such grim dispositions are too widespread to be ignored in discussions of ‘ethics’, ‘the art of medicine’, ‘professional competency’, ‘integrity’.