Much of what "happens" to the medical student depends not only
on what he brings with himn to medical school, but on what the
instittution offers him and asks of him. Kenneth Keniston, Ph.D.
THE MEDICAL EDUCATIONAL SYSTEM AND THE WHITE MEDICAL STUDENT
Despite the fact, or perhaps, because of the fact, that Medicine
even in our objectively technological society, retains much of
its' aura of mystery and sacredness, there are relatively few
studies concerned with who goes to medical school and what medical
education does to students. The best review article on the subject
was written by Kenneth Keniston, a staff psychologist at Yale
It seems apropos to begin this document with a conclusion
_ "...it may be that medical schools will have to
scrutinize far more carefully the human hazards of medical
practice and the informal lessons of medical school,
and to assist their students to understand and examine their now
largely automatic accommodations to the stresses of their vocation.
To attempt to retain human sensitivity and social responsibility
in the modern world is to oppose many of the most powerful trends
of our society; it is obviously not easy. But perhaps one place
to start is with the experiance of the medical student himself...
Medical students are sometimes treated as if they were merely
rote learners of specialized technical competence. But in fact
they are also human beings - distinctively motivated young men
and women who have chosen to undergo the often arduous initiation
into the vocational hazards of mediciine...this fact could be
more openly recognized by medical schools..." 1
The purpose of this document is to begin that process of
scrutiny from the dual vantage point of one who has completed
four years within the medical education system and one who is
an atypical medical student by accident of race. My ardent desire
is that the recording of what "happened" to me can be used constructively
for the institution of policies and programs which will effectively
transform Third World persons who have a desire to render health
care into persons universally acknowledge as being topnotch physicians
who happen to be Third World.
The transformation of Everyman into Marcus Welby, MD has
been analogized similiar to induction into shaman status in primitive
societies. The analogy, of course, is imperfect but in both processes
the acquistion and incorporation of status related behaviors,
attitudes, and attire are as important, if not more so, as the
acquisition and manipulation of the indigenous technological information.
The tracking of future practitioners begins long before the
period of formal training, too.
For white culture, there are three attributes postulated
in the pre-medical student which direct and encourage him to choose
medicine as a career choice. 3
First, there exists in the person a special sensitivity to
and concern with three psychological themes: death, suffering
Secondly, these persons are distinguished by a preference
for certain adaptive techniques, styles and defenses. Which is
to say that non-colored medical students react to anxiety-provoking
situations not by trying to live with them or escape them, but
by vigorous efforts to master, overvcome, or counteract them.
As a result non-colored medical students in crisis are oriented
primarily towards changing their environment rather than themselves.
Finally, these persons are distinguished by a capacity to
translate feelings into ideas to manipulate theses ideas and at
times to forget the feelings that originally underlay them. The
non-colored medical student confronted with personal anxiety or
stressful situation, them, will demonstrate behavior symbolic
of an adaptive style which is counter-phobic, alloplastic, and
obsessive-compulsive, placing special reliance on techniques like
isolation and intellectualization.4
When the initial and predominantly self-imposed discrimination
between those who profess an interest in medicine and who have
the aforementioned attributes from those who do not is completed,
then the official harvest of the wheat from the chafe occurs through
the medical school acceptance procedure.
Acceptance into the sanctum sanctorum is usually by approval
of a committee selected in some way to be representitive of the
religious, ethnic, socioeconomic composition and political- medical
orientation of the institution. Their job in turn is to select
only those applicants whose previous achievemnents and future
goals conform with the image of the institution.
Those who successfully run the gauntlet this far and gain
admission into medical school are by no means viewed as physicians.
Now, in addition to increasing the large amount of technical data
the entering medical student brings to the first lecture, the
medical institution begins the process of shaping the behavior
A digest of the salient observations by Keniston is in order
here. He states,
_ The physcian is required to confront without anxiety
the most tabood issues and activities of our society - death,
intractable pain, terminal illness, gross malformation, psychotic
disintegration, violating the sanctity of another person's body.
Further, the physcian is expected to assume responsibility for
other human beings who cannot care for themselves. He must accept
a more total responsibility for and authority over the lives of
others than is allowed any other professional in our society -
a kind of responsibility which evokes guilt, anxiety and profound
feelings of inadequacy in most persons....[Thus, to remain effective
in the routine responsibilities of medicine, the emotions become]
detached from the work of medicine; what remains in consciousness
are the knowledge and the skills of the physician....Furthermore,
the process of learning how not to react emotionally to the confrontations
of medicine gives added impetus to learning the subject matter
of medicine: acquiring medical knowledge is not only a way of
helping patients, but a necessary defense against the personal
anxieties that might otherwise be aroused....The student then
seeks the obvious solution - to become totally competent, knowledgeable
and skilled, so that in the end he can say with full confidence,
'There was nothing more I or anyone else could have done.'...
This is perhaps one of the reasons why many medical schools barrage
their students so unrelentingly with examinations, quizzes, rankings
and grades. Because such tangible evidences of 'where they stand'
help reassure students that they are 'really learning enough'.
Even at a medical school which omits examinations, impersonal
standards like the National Boards and highly developed informal
means of comparison between students help reassure them that they
are working and learning enough....5
Conversely, the students performance on various examinations
is taken by the medical school faculty as a prior evidence as
to the diligence with which the student is pursuing his degree
- high grades go to the "diligent", low grades go to the "lackadasical".
Poorly defined "non-academic" circumstances responsible for either
end of the spectrum are considered irrelevvant to the students'
performance - much to the disadvantage of the low grade student.
He acquires the onus of "non-motivated" which cause the faculty
to withdraw any initiative on its' part to extend extra help to
the student and thus impede the progress of the "well motivated".
If medical students do not often worry about the tabus
[of the laymen's society] they violate or the responsibilities
they will one day assume, they do worry about the effects upon
them as people of their automatic accommodations to their vocation.There
are monemts in the life of every medical student when he awakens
suddenly to realize that he is no longer reacting emotionally
to events, experiances, and activities that would once have terrified,
shamed or upset him deeply...Among students who have long prided
themselves on their detachment, there is least to lose, but among
those who pride themselves upon their sensitivity, sympathy, and
openess to their own feelings, to observe in themselves an absence
of anxiety, revulsion or fear can be surprisingly distressing.
Thus it haappens that many students wonder what medical education
is doing to their humanity, their sensitivity, and their capacity
for feeling. Among groups of first year medical students, met
to discuss the effects on them of medical school, the question
'Are we leaving the human race ?' recurs regularly and even monotonously....
Finally, the fear of 'leaving the human race' is often aggravated
by the reactions of non-medical acquaintances. The special attitudes,
expectations, anxieties and 'transferences' of others towards
the; medical profession begin to be felt by the medical student
very early in his career. Often at the very monent when he himself
is most worried about how to preserve his 'humanity', he encounters
contemporaries who react to him as if he were 'nothing but a doctor'...Thus,
some medical students begin to make rather deliberate efforts
to present themselves as 'good fellows',as ordinary human beings,
as open, unthreatening and non-judgemental people, so as to persuade
others (and incidentally themselves) that they retain their capacity
to respond in an ordinary human way.6
While it might be true the medical student is granted the
dispensation to violate certain tabus of the lay world with impunity,
transgression of the normative order within the medical world
results in inevitable reprimand. Furthermore, the students adherence
to medicine's value system is unceasingly monitored.
It is not by accident, nor is it unique, that out of fifteen
assessment criteria used at the Univesity of Utah to judge a students'
competance as a physician, 66% of that evaluation directly concerns
the students habits, attitudes and human relations. 7
The definition of "human relations" in terms of medical evaluation
is interesting. The term actually has little to do with the students'
ability to form a good rapport with other human beings, especially
patients, as one might suspect. It, to the contrary, evaluates
the students acceptance of the pecking order in the hierarchy
of medicine. There always exists some degree of sub rosa criticism
of those overly obsequious peers who "brown-nose it" or act like
"turkeys" in the presence of attendings, However, when 60% of
one's human relations evaluation is dependent on one's subservience
to attending and chief residents and an additional 20% is based
on whether your classmates approve of your conduct, there is more
than a grain of truth in the comment of a resident who said, "Any
bastard can get over if hae has soft lips on the asses of the