MS-Fifteen

Medical education has come a long way over a small handful of years.  While the student of the nineteenth century had encountered a profession of questionable favor and compensation, their education was often in name only, with a diploma related more to how much they could afford; a hurdle in their lives as physicians, but not likely representative of any deep challenge or upbringing into a moral culture.  Physicians through practice were taught to be independent, isolated, and indifferent to each other... their society was reflective of competition for patients rather than an interdependence for referrals and community.  Moreover, the relationship of the doctor towards their patients was one that condoned deception, partly because there was not yet the basis and authority granted by a shared science that physicians began to claim in the later years of that century.  Physicians became practitioners of an art that was more artifice than any veritable knowledge of media, practiced technique, or scholarly upbringing.

By the time of the 1910 Flexner report, improvements in public health, scientific inquiry, and transportation had already begun to set their mark on the practice of American medicine.  What is fascinating is how a showering of forces consolidated on the structure of medical education all at once, destroying numerous inadequate schools in the process, even in the midst of physician shortages and disparities.  By extending the length of medical training, defining their laboratory and clinical curriculum, and legitimizing the process of licensure, the process of defining what it meant to become a physician was granted to the academics, with the added 'benefits' of prestige, compensation, and authority later claimed by these new practitioners of the medical arts during the early and middle parts of the twentieth century...

I was born on the downslope of this golden era of physicians... past the ages of paternalism and patient autonomy, with a foot slipping into the ages of managed care and shared-decision making.  It was 1976, and I, a bicentennial babe, was the second of three to a pair of doctors, one all business, and one all discontent.  My brothers chose a life in the arts, and I chose what some probably consider a science.  However, I am ultimately an artist in my ways and a romantic at best.  My thoughts of the doctor-patient relationship are often dreamy, and despite an occasional difficult patient encounter, I reconcile ways where I could have been more empathetic and thoughtful and sometimes even funny.  Realistically, human interactions sometimes fail... but could I have been more?

I have been a consumer of academic medicine for awhile... I've technically never left the auspices of medical school per se, despite receiving a medical degree and yet another doctorate.  I'm a board-certified surgeon, but still in an extended process of training as a fellow in surgical oncology and clinical ethics.  At least part of that training includes one of my favorite roles:  teacher.  Actually, I technically only facilitated a discussion today...  and the students by far did most of the teaching...

Today was the first day of a course in the Doctor-Patient Relationship for the MS-I's, where (paying) first-year medical students sit around a table to discuss topics relevant to their entry into clinical practice.  Their discussion is led by MS-IV's, bright-eyed from their new-found clinical experience, eager to provide their juniors with insight and wisdom of what they will soon become.  Strangely, I was in the ranks of the clinician proctor, world-weary and tempered from experience, but in reality quite aware that in this game, you are always learning something new... from every patient...

A strange sense of deja vu swept over me as the students began to give their opinions, which simultaneously showed their naivete and their genius all at once.  They spoke of times they were patients with utmost vulnerability.  They role played as if they were physicians...  They spat out a mixture of paternalistic doctor and patient autonomy advocate all rolled into one.  They talked about what they might say if they were refused by a patient because of their status as a student, then they listened intently as their senior refined an answer that worked for him.  They debated the validity of the word 'cancer', as it could be misinterpreted by a patient when disclosing information about a prostate biopsy.

We discussed a classic paper, actually a speech originally presented before medical students of Harvard Medical School, first published in 1927... Francis Peabody's 'The Care of the Patient'.  The students remarked how timeless and moving the language was, and were it not for the mention of 'tonics', they were apt to take it as contemporary...

"Hospitals... are apt to deteriorate into dehumanized machines."  

 "When a patient enters a hospital, one of the first things that commonly happens to him is that he loses his personal identity.   He is generally referred to, not as Henry Jones, but as 'that case of mitral stenosis in the second bed on the left'."

"Medicine is not a trade to be learned but a profession to be entered."

Peabody was ultimately criticizing the "amazing progress of science in its relation to medicine during the last thirty years, and the enormous mass of scientific material which must be made available to the modern physician." Has anything changed?  Perhaps, that we now talk about it... sometimes openly, and sometimes in small groups...

The fourth-years imparted their inspiration from the closing paragraph, as they noted that in a busy hospital setting, it is often the lowly medical student who can give the most to a patient... they had clearly gained the most as well:

"The good physician knows his patients through and through, and his knowledge is bought dearly.  Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.  One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Sometimes it is good to have a reminder of where we stand... where we are always students of our patients...

Sabha Ganai, MS-XV

References:
Peabody FW.  The Care of the Patient.  JAMA 1927.
Starr P.  The Social Transformation of American Medicine.  Harper Collins: 1982.