Chapter Six

Non-Colored Students In Crisis

The Medical Student Kenneth Keniston

In primitive societies, those who would become shamans or witch doctors must often undergo curious rites of passage. At an early age, the future shaman is frequently set apart from others by his conviction that he possesses special healing powers, which may be transmitted by virtue of his birth into a healing clan; from the start, his fellow tribesmen endow him with a special mana of one who will confront the ultimate mysteries of life and death. On reaching maturity, and perhaps after enduring ritual ordeals to test his vocation, he is apprenticed to the elders whose ranks he will join. Often he is secluded from his fellows for may years, submitting to painful initiations to establish and consolidate his calling. In these years, the secrets and stigmata of his guild are passed on to him - frequently an arcane language, dating from the distant tribal past, a special manner of relating himself to the sick and the dying, and an elaborate technology of herbs, charms and incantations to preserve the living or hasten the dead upon their way. Upon emerging from his prolonged initiation, the young shaman may be expected to assume a new name, to don the distinctive garb and amulets of his order, and to accept the ambivalent weight of membership in his feared and powerful guild.

The analogy between the training of a shaman and the education of a medical student is of course
Chapter Six

far from perfect. In most respects, modern medical education is technically justified to a degree that is matched by no primitive initiation system. Yet this analogy at least suggests that those who enter the healing profession may be distinctively motivated to confront actively the issues of suffering, death and care which most of their fellows anxiously avoid; and further, that their educations may (and indeed should) teach them not only the specific skills of medicine but more general techniques for coping with the vocational anxieties that must inevitably plague the healer. Finally, the analogy points to the fact that in all societies, those who care for the sick are set apart from the common run of mankind and are selectively misperceived by their fellows through lenses of wish, envy, fear and admiration.

Given the obvious importance of understanding who goes to medical school and what medical education does to students, one might expect a plethora of studies on medical students and medical education. But perhaps because even in our own nominally rational society, medicine retains some of its aura of mystery and sacredness, studies are few and far between. To be sure, teams of sociologists have studied the ways medical students organize themselves "to beat the system" and to manage the vast amounts of information which they "should" learn.1 Yet such studies concentrate largely on the areas in which medical education is most like other kinds of education. What also need to be studied in depth are those processes that are distinctively medical - that distinguish the medical student from his other pre-professional fellows, and that might account for the special impact of medical education upon future physicians.

In the absence of the many studies required to
A Rose Don't Grow in Sand

provide exact information about "the medical student", anyone who speculates on this subject had best begin by announcing his disqualification. My own are numerous; I am not a physician, although I teach in a medical school. Furthermore, as a psychologist who teaches in a department of psychiatry, I doubtless meet more than my share of medical students who (a) are disaffected from medical school and/or (b) arrive in medical school convinced that medical education is merely "the price one pays" for becoming a psychiatrist. (Be it noted that a goodly number of such students eventually end up in internal medicine or surgery.) Some of my best friends are doctors (real doctors, that is), but I can occasionally detect amongst my feelings about them vestiges of the awe I felt as a boy toward my white-coated pediatrician. Finally, I teach at the Antioch of medical schools, and institution whose image and admissions procedures selectively recruit students with broad interests who believe they will learn their profession best when unencumbered by examinations. Thus, my chief qualification for writing about medical students is an interest in student development, and the fact that after five years of working fairly closely with medical students,2 I still retain some of the curiosity of a visitor from another culture.

With these apologies, let me proceed to speculate about "the medical student". First, there is obviously no such thing as the medical student; they come instead in a variety of sizes, shapes, talents and psychologies. Many years of studying college students, some of whom have turned toward or away from medicine, indicates the enormous variety of motives, talents and experiences that enter into the decision to become a physician. Amongst able college freshmen, "doctor" is one of the most common career choices; yet fewer than half of these
Chapter Six

students enter medical school. Indeed, something may be learned about those who do enter medicine from those who are "deconverted" during college. Some students abandon medicine because they are told they lack talent (organic chemistry is particularly telling); others, because they cannot stomach the prospect of seven to nine years of education after a B.A.; others, because they are lured to Ph.D's by more academic interests;; and still others - a significant group - because they agree with the student who writes, "Though there certainly are admirable people who need a sterile, scientifically defined mode for relating to people (who also need the superficial closeness of medical practice). I don't think I am among them."

A similar variety of factors can inspire the "convert" or the "persister". For a few, an idealistic interest in public service makes medicine a logical choice; for others, the discovery of scientific aptitudes leads to an interest in medical research; for others a family tradition of medicine is clearly important. 3 But for most, such "public" motives as these are intertwined with more personal experiences themes and values, often subtle and unconscious, that co-determine and "over-determine" the choice of medicine.

Much has been written about the psychodynamics of physicians which might by extension, be applied to the motivations of those who enter medicine. Yet most of these speculations seem to me excessively non-specific. For example, discussions of the "sadism" of the surgeon or the "voyeurism" of the gynecologist fail to explain why such widespread unconscious tendencies should find special expression in medicine, where they must be so highly disguised. Nor does the recent spate of muck-raking tools that exposes the conservatism, lust for power,
A Rose Don't Grow in Sand

desire for money and social prestige of physicians4
explain very much; these qualities could equally well be said to characterize the lawyer, the merchant, the politician, and so on. Similarly, that "sterility" or "excessive detachment" that purportedly characterizes the doctor-patient relationship can be found just as easily in lawyer- client, seller-buyer, teacher-student relationships, or for that matter in any formally defined professional role.5

Were I to conduct a study of those who elect medicine as a career my own hypotheses would be different. First, I would propose that medical students as a group may be drawn to medicine partly because of their special sensitivity to and concern with three psychological themes: death, suffering and care. Secondly, I would speculate that medical students may be distinguished by a preference for certain adaptive techniques, styles and defenses - specifically a propensity to counter, master and overcome sources of anxiety, a tendency to react to stress and anxiety by an active effort to change the environment, and a highly developed ability to respond intellectually to troublesome feelings.

To speculate about the motives of medical students is of course dangerous; in the end, everyone's motives are different. Nonetheless, comparing premedical students with other undergraduates and medical students with other pre- professional students three psychological themes seem more salient amongst the former. First, medical students are frequently individuals with a long-standing need for, enjoyment of and capacity to tolerate being in a caring, providing, dispensing, nurturing relationship to other people. The origins of this theme are of course varied; in some a pattern of family relations throughout childhood and
Chapter Six

adolescence in which the student has had much practice in this role; in others, a highly developed capacity to identify themselves with those for whom they care. A second theme in other medical students concerns the related issue of death. It is no uncommon for medical students to have chosen medicine after a death of a family member or close friend, sometimes with the quite conscious desire to learn how to fight wasteful death. Similarly, intimate personal contact with physical or psychological suffering, whether in themselves or in others, seems to have disposed other students toward a vocation in which their lives will be partly devoted to combating suffering.

Concern with these psychological themes is of course very widespread in any society, and in no way requires a choice of medicine as a career. But when special sensitivity to these themes is combined with a preference for certain adaptive techniques in a young man or woman of high talent and adequate resources for prolonged professional training, medicine does become more likely as a career. Three ways of adapting to stress seem to me especially prominent amongst medical students. First, many medical students react to anxiety - provoking situations not by trying to live with them or escape them, but by vigorous efforts to master, overcome, or counteract them. Confronted with a problem, the medical student is disposed to head straight into it and try to eliminate ti. Second, as a group, medical students are oriented primarily toward changing their environment rather than themselves. Compared with graduate students in the liberal arts medical students are notable for the speed and zeal with which they attempt to devise practical, well- organized plans for changing things; they seem to me less inclined to examine their own motives, feelings and fantasies, much less to advocate self-reform
A Rose Don't Grow in Sand

before reform of the world. Finally, and perhaps
most impressive, medical students, like many other students with developed scientific ability, generally possess a considerable capacity to translate feelings into ideas, to manipulate these ideas, and at times to forget the feelings that originally underlay them. Thus, whether he confronts a personal anxiety or a stressful situation, the medical student is less likely to be interested in or aware of his own feelings than to be preoccupied with understanding intellectually what is happening, planning a rational course of action, or studying the theoretical implications of the problem. 6

No doubt these speculations about the motives and defenses of the in-coming medical student are over-generalized, or perhaps simply incorrect. Motives for choice of career are always mixed, and differ from person to person. And even if we grant that many medical students may have certain outlooks in common, there is clearly more than one "type" differs among medical schools. 7 But it is also clear that medical students are a highly self- selected group who arrive in medical school with a set of developed abilities, motives, adaptive styles and values that must be taken into account if we are to understand the impact on them of their medical educations.

To one who comes upon medical education without having been through it, the human impact of these four years is immensely impressive. Not only do students master prodigious amounts of scientific and clinical information, not only do they gain notable clinical skills, but they learn attitudes, adaptations and orientations of a kind that medical school catalogs rarely discuss.8 In focusing on these "other" leanings, I do not mean to deprecate the importance of technical learning; yet if we ask 61
Chapter Six

"What happens to medical students in medical school?", the acquisition of technique and information is clearly only a part of the answer.

The stuff of medicine is, of course, the effort to alleviate suffering and cure illness, the struggle against pain, misery, malformation and death. the physician is required to confront these aspects of the human condition daily and directly, and without flinching. Somewhere in the course of his education, he must have learned to face without anxiety the most tabooed issues and activities of our society-death, intractable pain, terminal illness, gross malformation, psychotic disintegration, "violating" the sanctum of another person's body. further, the physician is expected to assume responsibility for other human beings who cannot care for themselves to "take the patient's life into his own hands". 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 evoked guilt, anxiety and profound feelings of inadequacy in most men and women.9

Seen from this point-of-view, many of the formal exercises of medical school have a double function- not only do they teach technical competence, but they prepare the student for the psychological hazards of his vocation. The first incision in the cadaver is the paradigm for many similar confrontations-the first lumbar puncture, the first pelvic examination, the first terminal patient, the first acutely psychotic patient, the first death. In each instance, medical students tend to respond in similar ways; an initial fleeting phase of anxiety, dread, or fear rapidly gives way to an effort to learn about the object of anxiety,

A Rose Don't Grow in Sand

to develop the intellectual "knowledge and motor skills to do a competent job, to master the task at hand. The emotions are largely detached from the work of medicine; what remain in consciousness are the knowledge and skills of the physician. If I am correct in suggesting that medical students possess an unusual tendency to move toward the object of anxiety, to seek to change the external world, and to replace feelings with thoughts, then all of these adaptations occur around the issue of responsibility. The student's dilemma can perhaps be best stated existentially; he will eventually have "absolute" responsibility for and power over many of his patients; yet he is a fallible, sometimes ignorant, and often careless human being. He soon realizes that it will never be possible for him to know all of modern medicine; and he further learns that in many areas, relatively little is known that might be of help to patients. Yet these same patients will put themselves in his hands, trusting in his abilities. And of course all of his patients will eventually die.

The obvious solution is for the student to attempt 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." He is thus powerfully motivated to learn-and to see reassurance that he is learning-the tools of his profession. Indeed, perhaps one of the reasons why many medical schools barrage their students so unrelentingly with examinations, quizzes, rankings and grades is that 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
Chapter Six

working and learning enough. 11 Yet behind the vexed problem of "how much is enough" in a filed where no one can know everything, lies the continual struggle to feel adequate to the life-and-death responsibility that will one day rest on the physician's shoulders. Even the long years that elapse from the start of medical school to the end of the residency can be seen partly as time for the student to learn how to forgive himself for his inadequacies and mistakes.

The increasing ability to confront without conscious anxiety the tabooed issues around which medical practice revolves, and the ability to accept without guilt the life-and-death responsibilities of the physician - these are rarely the subject of much conscious reflection or discussion. "Learning" clearly occurs in these areas, as can be attested by the obvious fact that physicians accept comfortably confrontations and responsibility which the same men and women, as medical students, could not have approached without massive and incapacitating anxiety of guilt. Thus, as a rule, anxieties about death, suffering, pain, etc. are either repressed or quickly suppressed; and fears about one's adequacy to the responsibilities of medical practice are quickly channeled into efforts to learn the subject matter well. The student's pre-existing adaptive techniques stand him in good stead in medical school; and the undeniable satisfactions of medical school stem partly from the fact that students are learning to deal un-anxiously with issues of great personal concern to them, using their own preferred methods of adaptation.

But if medical students do not often worry about the taboos they violate or the responsibilities they will one day assume, they do sometimes worry about the effects upon them as

A Rose Don't Grow in Sand

people of their automatic accommodations to their vocation. there are moments in the life of every medical student when he awakens suddenly to realize that he is no longer reacting emotionally to events, experiences, and activities that would once have terrified, shamed, or upset him deeply. For a few, such realizations may be unequivocally positive; but for many, relief and triumph are mixed with concern lest in some way the student is becoming depersonalized, automatized, mechanized, or in some other way losing his capacity for ordinary human responsiveness. It is as if, especially during the first years of medical school, the students were frightened lest the defenses elicited and strengthened by medical school will spread, cancer- like, into all areas of his life. 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 openness to their own feelings, to observe in themselves an absence of anxiety, revulsion or fear can be surprisingly distressing.

Thus it happens 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. And the urgency of this question seems partly related to the growing awareness of students that they have simply stopped reacting emotionally to experiences (like dissecting a cadaver) about which they were extremely apprehensive in anticipation. but relatedly, many students feel that their choice of medicine has "cut them off" from other interests, avocations and experiences. Here, too, some students feel that they have more to lose than others; for the student
Chapter Six

who arrives in medical school from a field like French Literature, Sociology, or European History, the "final" choice of medicine is often felt to involve a loss of some valued aspects of himself, generally a part associated with the feelings he no longer feels.12

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 moment 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." He may find himself consulted solely because of his supposed medical competence; he may find the "medical student" stereotype an obstruction to personal relationships; he may inspire in others complex feelings more related to his status as a future physician than to his actual behavior or personality. It is partly for this reason, I suspect, that some medical students begin to make rather deliberate efforts to present themselves as "good fellows", as ordinary human beings, as open, unthreatened and non- judgmental people, so as to persuade others (and incidentally themselves) that they retain their capacity to respond in an ordinary human way.

More could be said about other informal "learnings" that go on in medical students around such issues like authority, 13idealism,14 and intellectual curiosity.15 But however we define the transformations that medical education induces in its students, it should be noted again that there are great differences not only in the reactions of individual students to the same medical school.16

A Rose Don't Grow in Sand

but in the effects of different medical schools on initially similar students. Although medical training is by its nature pre-professional and largely geared to the requirements of medical practice, there is a whole spectrum of medical educational "climates", ranging from narrow vocationalism to something akin to a liberal arts outlook. Similarly at some schools, faculty-student relations are modeled on warfare; while at others, students and faculty feel themselves partners in the larger enterprise of medicine. Much of what "happens" to the medical student depends not only on what he brings with him to medical school, but on what the institution offers him and asks of him. 17

The great differences in medical students and the equally great variations in medical schools make predictions about "the medical student of the future" extremely hazardous. If the much-discussed "student existentialism, " with its emphasis on personal encounters, face-to-face confrontation and openness to experience, continues and affects the current crop of pre-medical students more and more of tomorrow's medical students will have "a lot to lose" and will therefore be reluctant to assume an attitude of "coldly scientific" detachment toward their subject-matter or their patients. such students, if encouraged by their educations, could be expected to show unusual sensitivity to the human aspects of medical practice. Similarly, a continuation of the minority mood of student activism is likely to influence at least some pre- medical and medical students, who will bring an increased sense of political urgency and social responsibility with them to medicine. Such students, if they are not made unduly cynical by their medical educations, could be expected to take a heightened interest in the public and social aspects of medicine.

Chapter Six

But "the medical student of the future" depends in large part on the medical school of the future. In these remarks, I have reflected my conviction that medical schools are unusually powerful institutions in their capacity to affect the outlooks, styles, and defenses of their students. I have here emphasized the "adaptiveness" of the informal learnings of medical education-their congruence with the vocational hazards of medicine. But it may not be amiss to wonder whether such learnings are always adaptive-whether, for example, the confrontations of medical education may not create (or consolidate) in some students a defensive detachment from the emotional substrate in themselves and from the feelings of their patients. Similarly, one may wonder whether the responsibilities of medicine may not push some students into a defensive attitude of omnicompetence with their patients (and others) that militates against their being humane physicians. In brief, it seems possible that certain medical schools, with some students, help produce what we might term "professionally-patterned defects" - human and vocational disabilities that are informally "learned" through the largely unexamined years of medical education.

We know that good medical care requires from the physician not only detachment and technical competence, but humane sensitivity and wisdom, plus a high sense of social responsibility. there is reason to expect that more and more students will arrive in medical schools with these latter qualities. but whether all of tomorrow's medical students will be able to preserve and strengthen these qualities throughout their medical educations seems to me more open to question. My argument here suggests that for at least some students, the experience of medical school may serve to create or

A Rose Don't Grow in Sand

consolidate barriers of cold detachment and purely technical competence between the future physician and his future patients. On the one hand, these barriers are to some extent necessary in helping the physician deal with the anxieties inherent in his difficult vocation. But on the other, they may become rigid over-elaborated and inflexible, partly because their appearance is so automatic and unexamined.

Thus, 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 18. But perhaps one place to start is with the experience of the medical student himself. for there is much evidence that we come to treat others as we have been treated ourselves. 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 medicine. If this fact could be more openly recognized by medical schools, and if the effort to teach competence could be supplemented with an effort to strengthen students' sensitivity and openness to themselves and others, then future physicians might be better supported in their desire to treat their patients not merely competently, but wisely, responsibly, and humanely.