‘In-doctor-nation’: Socializing into Medicine

I’m still here! Apologies for the extended absence; the past few months have seen a couple big transitions for me, moving cities and schools as I finished my last academic program and started medical school back in the US. Now that I’m somewhat settled I want to get back to writing here at least somewhat regularly; posts might be a little shorter or less frequent mostly because my schedule this year is trying out to be quite a bit more demanding than it was last year. Also given that medical school is the thing taking up a lot of my headspace at the moment, there will probably be quite a few more posts about health and medicine: the next few posts in particular I imagine are all going to be quite medical as I document some of my initial thoughts.

I’ve spent the past three weeks beginning my medical education, which has meant shuttling back and forth between lectures, and dissections, and simulations, and mock-patient interviews, and more lectures. It’s been an exciting, draining, confusing few weeks, in no small part because of the overwhelming amount of information that is continually streamed at us. What makes it even more mystifying is that lack of clarity on what we’re actually responsible for knowing. While a lot of the information given to us are facts and names that we are expected to be able to regurgitate on demand, there is a large portion of the education we’re receiving that all seems to be hinting at topics that we’re going to get in depth later, if at all.

I don’t think that the time we’re spending in these classes is due to poor curricular planning, or poor judgment on our part regarding what we actually need to know (though time and exams will tell if I am right about that last point). What I think what those classes are meant to do, what much of these first few months are meant to do, is begin a process of enculturating us into the field of medicine. Everyday we are surrounded by a very specific language, a way of approaching problems, norms of behaviour and of social relations (the amount of time we’ve spent discussing ‘professionalism’, and what that term means in a medical context, is worth a post on its own), and whether or not we remember the specific content that they are wrapped in, it is that messaging that stays and frames the way we see our work. Moreover, the entire structure of our program – and similar programs throughout the country – are set up to normalize this culture as completely as possible. The very fact that we are with our peers and medical faculty for the majority of each day (and many live with other med students, making that contact near-constant) means that his mode of being – this referencing of anatomical positions, this habit of always being ready with an answer – becomes something common to people all around you, until it feels like it’s common to everyone else as well.

A lot has been written about the ‘hidden curriculum’ in medicine, and what it does to medical students’ experiences of their education. What I wanted to focus on are two points that I am noticing most in my own experience: the way that this enculturation leaves little room for reflective or critical thought, and the way that it turns medicine into an exclusionary space. One of the things I have felt most during the past three weeks is the simple, insidious fact that it’s hard to do things when you’re tired. When you’ve had long, intellectually and physically draining days, and then are meant to be continuing to engage with academic material independently, that leaves very little time to be reflecting and thinking critically about what you’re doing and learning. And even the time that you do have free, it becomes difficult to use that in a productive way, because all you want – and need (self-care matters, after all) – is to rest and re-charge. Feeling the effect of this myself I can see how even students who want to engage critically with their curriculum, push back on things they find unsuitable or problematic, could find it very difficult to do so, simply because there isn’t enough energy or time left. It’s one potential reason I see for why medical curricula have taken so long to change, and there is a part of me that feels this is an intentional move on the part of those development medical programs: the more you can keep students engaged in the structure and demands of medical school the less likely they are to resist anything within them. And of course, if this is how it works within the elite, professional world of medical school, the same logic applies many times over in any highly demanding area of work.

The second development I am seeing is the way that this enculturation builds an environment that is exclusive and that – intentionally or not – open about its exclusivity. One way i see this working is through our language. Our main academic commitment at the moment is our gross anatomy course, meant to provide us with a familiarity with the geography and structures of the body once we begin to study its pathologies. Whether or not the material we’re learning will ultimately be of use is unclear to me; what it has already produced is an entirely new vocabulary for describing the body, a new set references points and, due to our regular cadaver dissections, a new comfort with handling and talking about handling a deceased human body. All of this is of course a language that very few people in the world have access to, which itself is not necessarily terrible: lots of fields have specialized jargon, and a highly specialized, highly specific language can be more efficient and effective for communication with peers in that field. Where it ends being frustrating and potentially harmful is when that language is taken out of the context of that particular field, and becomes a marker of exclusivity. Making jokes about anatomy or comments about cadavers is fine in the bubble of our classrooms and labs, but outside of those spaces these comments – aside from potentially being uncomfortable for many people to hear in the first place – are markers of being part of a specific world. More than that, when the world is medicine, those markers aren’t neutral: they are signs of privilege, of power, of influence, signs that compound upon the other markers that we carry as med students particularly when we are in the larger city that our school is in (it is, for instance, perhaps no surprise that the majority of our class is White and Asian while the majority of the city is Black). While the enculturation process we go through works in part because it becomes so easy to feel that everyone around us is working and thinking in the same way (which is not true even within a group of medical students), we need to be mindful of how casual exhibitions of that culture outside of our spheres is perceived and understood.

The totalizing and insulating effects of subcultures are clearly not isolated to medicine, but I do think it is an interesting example (not just because I happen to be in it) because ostensibly the purpose of the profession and the culture it sustains is to serve those outside of itself. How that culture works then both in creating professionals who are mindful and reflective of its workings and relations, and how it functions in contact with those outside of itself are crucial to how medicine as a profession functions. Doctors and medical students alike need to be mindful of the world that they work in and its boundaries if they are to provide services in a way that is welcoming and inclusive of patients.

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