October 22, 2017
Medicine is a guild, an association of barber surgeons, apothecaries, anatomists, and philosopher/scientists. Like all guilds, the Medical Profession subjects potential new members to an apprenticeship before assigning journeyman status. In Medical School, the apprentice physician learns how to walk, and talk, and act like a physician. Medical jargon is complex; it is certainly not to be understood by a layperson. The student learns to wear a white coat and stethoscope, and most importantly, how to act in the presence of the patient. The apprenticeship is difficult with long hours spent studying, reading, and sitting in lectures. Moreover, there is the time spent shadowing journeymen and masters as they go about their business. Not every student completes the apprenticeship. Those that do are altered, more knowledgeable, more empathetic, but also more able to tolerate the pain and suffering of others.
Dear Medical School Class of 1987:
It has been 30 years since we graduated from medical school. Where has all the time gone? A noted, if fictional archeologists once said, “it’s not the years, it’s the miles” that make us feel old. I have traveled many miles since leaving medical school. I have seen and done things that you would not believe: except you would, because you are all doctors as well. You recognize just how weird it is to practice medicine. The journey began as we walked on campus in September 1983. God we were young, well most of us anyway. I remember who I was, who we were, and why we chose to become physicians. I recall the times good and bad, the stress, the excitement, and the frustration. In retrospect, it is easy to see how the years in medical school changed us. Most of all, I recall how we made it through school together. Time has passed, but the memories are strong.
Let’s agree at the start, that I was a brash, self-involved, poor excuse for a human being when I began medical school 34 years ago. To be fair, I am the first-born son of a Filipino surgeon and his American Nurse wife. I was raised with confidence and independence, encouraged to excel intellectually and athletically. In other words, I was a perfect medical student for the time. Many professions claim to choose the “best and the brightest”, medical school selection committees are no different. They weigh and measure each applicant, looking for demonstration of drive and intelligence. Success in academics is prized, though it helps to also show athletic prowess or virtuosity in the arts. The committee is looking for winners; for young men and women who have proven they can succeed physically and intellectually.
Not to sound conceited, but medical schools really need the best possible students. Practicing Medicine is hard, and doing it well is even harder still. Learning and retaining the breadth of Medicine is mentally hard. Working long hours on your feet and at the operating room table 24/7/365 is physically hard. Sharing the pain and suffering of your patients every day is emotionally hard. Accepting the responsibility for guiding a patient to a successful outcome is philosophically hard, and sometimes overwhelming. With great power, comes great responsibility (Peter Parker’s dad was probably not the first to say so), and risk. Doctors suffer more than their fair share of divorce, drug and alcohol addiction, and suicide. To be fair, there are many hard, difficult, or downright dangerous vocations in the world. Physicians are not unique in the hours they work or in their dedication to their profession. Silly humans; our decisions are not always rational or made with complete information.
No one can know what it is like to practice Medicine until he or she is there, at the bedside, trying to make a diagnosis and restore a patient to good health. None of us really thought about the toll exacted by the profession. We wanted to help our fellow man (really, did anyone of you say that in your admission essay?), or make a good living (there are easier ways to make money), or have a challenging, broadly rewarding professional career (that was my reason). Some of us went into Medicine because it was the family business or because we couldn’t score well on the LSAT (joke). In the end, the selection committee sorted through the candidates looking for those motivated students with strength and determination, and most importantly, resilience. Mostly, they got it right.
I entered Medical School with an arrogance born of past success. Admit it, you were accustomed to being the smartest person in the room. The Basic Sciences Building lecture hall is not your average room however. Every medical student is a nerd. Our class, like every other medical school class, was replete with high school and college valedictorians, scholarship winners, and graduates Magna Cum Laude. There were high school and college letter winners, captains of their teams. Never mind the singers, musicians, and writers. As it turns out, none of it matters. Not one bit. Professors don’t care. Licensing and credentialing boards don’t care. Patients sure as hell don’t care. What matters is how you perform for the patient. That may sound specious, but think of a performance in the broadest sense. The best acts require style and skill; in short, total command of the medium. As students, we had the potential to be great, nothing more.
Potential can be a promise and a curse. There is nothing quite so damning as wasted talent and falling short of yours and others expectations. Medical School gives first proof to the student’s potential in the form of too many books to read, classes to attend, and hours to spend on hospital wards. Medical training is time consuming; there is a lot to learn. Ultimately, a physician’s breadth of knowledge separates him or her from other medical providers (don’t you love being called a provider?). You cannot diagnose a problem if you are not aware of its existence. Google away, but you need context and a base of knowledge to apply the results of that Internet search. In medicine, the unknown knowns get you into trouble. Medical knowledge increases and changes every year. The old saw, that half of what you learned in school will be wrong or outmoded in 10 years, is probably true. It is a good thing that we were all chosen for our ability to acquire and process information.
It is much harder to learn the social aspects of Medicine. Doctors are socially odd people to start with; medical training gives some justification to that oddness. One does not have to have a high emotional quotient to practice Medicine. Yes, it helps, but we know that there are many nearly autistic respected physicians. Ideally, a good physician will find a balance between empathy and distance. Too much empathy leaves you unable to care for patients. Without a filter, shared suffering can be unbearable. Excess distance though, leaves the physician cold, and unapproachable, and ultimately unable to connect with patients and family. Finding the correct balance is not easy. It is an awkward, sometimes embarrassing, continually challenging, and absolutely necessary process. In the end, the student first has to acknowledge his or her humanity before locking it away behind a veneer of professionalism. A Doctor must be able to do intrusive, painful, and potentially dangerous things to patients, while understanding, but disregarding the patient’s discomfort.
Do you know the difference between a surgeon and a serial killer? The surgeon puts their victims back together. Inappropriate, I know, but medical school was a time of social strangeness and adjustment. There was the first pelvic exam done on a paid young female “patient” with three other classmates watching (Voyeurism? Exhibitionism?, but no this is Medicine). Of course, there was the first digital rectal examination done on an older veteran (latent homophobia?). I have trouble putting on gloves when I am anxious; my hands sweat. Struggling with your gloves makes a poor first impression with patients. Patients were so gracious. To this day, I am grateful for their tolerance and support.
I remember learning to ask personal questions about health, mental wellness, sexual habits, and vices without stuttering or blushing. Yes, there is a proper way to wear and use a stethoscope, and the sounds mean something. Good thing the library had tapes of heart sounds to study. Yes, I still have the tuning forks. No, I have never used them in my practice (I am a surgeon, remember?). There are so many acts to master including wearing a white coat, scrubbing and gowning for surgery, starting an IV, drawing blood, putting in a urinary catheter, injecting, sewing, and cutting with a scalpel. Every aspect of the physical examination was new; examination of the throat and ears or back of the eyes. Some actions were rendered less personal; breast examination, testicle examination, and palpation for nodes. I was nervous and self-conscious through all of it. I nearly fainted in a hot exam room one day in August while watching a resident perform a bone marrow biopsy. I still recall the crunch of the bone as the needle was twisted and driven into the protesting patient. More local I thought, or more sedation for the patient, or me.
I remember my social evolution and I remember sharing in that development with my classmates. That was the thing; we all had the same experiences, the same points of hesitation and anxiety. Whatever you might think of me, I was not socially adept going into medical school. I made a conscious effort to get involved, to get out of my cubicle and interact with people. It was easy to do in our class. We were young with an average age of 24; most of us were fresh from college. A few of the class had not yet turned 21, and of course, could not drink with the rest of us (sure). We were still a state school at that time; the class was evenly split between University of Oregon and OSU graduates mixed with a few “privileged” students who attended private out of state schools (I see you Mount Holyoke and Stanford graduates). In short, we were all young Oregonians. Heck some of us went to high school and college together before entering OHSU. A shared background made it easy to bond and to be supportive. And bond we did.
I remember the first after class visit to Ward 77, meeting some guy named Bongo, and a host of other reprobates. We shot a lot of pool, and had a little beer to drink. We played some really good, and some really bad basketball at the Student Activities Building. We took vacations together, and spent free time and class time at beach houses (the benefit of being local). There were bars to visit late at night after studying, and class parties that were sometimes out of control. My social game improved, if that is the right word. It certainly changed. I learned to speak with other smart people. I found my voice and some limits; I made mistakes and learned from them. I was not alone.
I do not mean to wax nostalgic about Medical School. The memories are just so vibrant; it is easy to ignore the rose tinge. We shared experiences; we felt the same emotions.
Along the way, we struggled through the tests and the board exams, learned to walk into an exam room with confidence, and found a way to function on little sleep and crappy hospital food. I learned to drink coffee, lots of coffee. Others developed, or continued, their nasty diet Pepsi habit. We all were changed, we grew up, and a few of us fell behind. Intensity of experience makes memories stronger. Maybe that is why I remember you, my classmates, with such clarity.
Groucho Marx famously said that he would never want to be a part of a club that would accept him as a member. The implication was that Groucho was a degenerate, and that joining a club of other degenerates just affirmed his worthlessness. I love the Marx Brothers, but I disagree with Groucho on this matter. I want to be a doctor; I want to be a member of club. That was the lesson I learned in Medical School. Physicians are dedicated, hardworking, intelligent, and altruistic. Physicians are not perfect, but overall, they are good people. I saw all of that and more in our class: Talent and humor, friendship, love, and loyalty; all the best that humans have to offer. Acceptance into the group affirmed my own worth. I remember who we were, and what we shared 30 years ago. We are classmates, we are friends, we are family, and we are physicians.
I could lie and say we all look the same thirty years later, but why? I was impressed at how easy it was to pick up a relationship after so much time apart. Reunions can be uncomfortable. We went through medical school together, sharing many of the same experiences. Apart, we are still sharing professional success and setbacks, divorce illness, and death. Life is always interesting. We have all traveled many miles. We look good though, and happy, just as we did back in the day.