The Etiology and Symptomatology of Emotional Problems in Third
World Medical Students

Cultural Shock: the experiance of disorientation that occurs when
an individual finds himself among people who do not share his
fundamental premises. Usually, disagreement over abstract ideas,
or variation in modes of dress, eating habits, and other daily
routines can be adjusted to fairly readily. Acute culture shock
is most likely to be experianced when expectations about personal
feelings, and interaction are violated.

The largest symposium audience at the tenth annual SNMA convention
was present at the symposium on student mental hygiene and mental
health. The speaker was Dr. Allyce Gullattee, a psychiatrist at
Howard Medical College, Freedman's Hospital, Washington, D.C.
and a co-founder of the SNMA. Although Dr. Gullatee is hightly
respected in the Black community, the audience was not assembled
so much to hear Dr. Gullattee, as to come together and expiate
its own sense of anxiety, frustration, and emotional problems
which had been engendered in them by attendence at medical colleges
all over the country.
One predominant theme which came from this symposium was
that students felt they were undergoing a process of identity
loss, alienation from their communities, alienation from their
medical school peers. Students frequently spoke in terms of inadequacy
of availability of a critical mass of Black people to support
their own sense of self-worth and "Blackness".
The term "critical mass of Black people" was defined as the
minimum number of Black students necessary to support the presence
of other Blacks so that at least in numbers there was some feeling
of unity. 28 When ther is not a critical mass of Blacks the students
universally tended to feel alienated; where ther were few in number
in therms of sexual groups, there were frequent complaints of
problems which were concerned with sexual and role identity, which
were concerned with negative image of self. In short, the students
felt they were trapped in an environment in which they were undergoing
constant cultural shock without the benefit of a therapeutic environment
to renew their spirit.
Concensus agreed that if the etiology of emotional disorders
among Black medical students had a common basis, then the symptomatology
of these emotional disorders also, had a common expression.
In first year students, Dr. Gullattee explained, the phenomenon
of euphoria is common, especially in the initial grading period.
Perhaps, it is because of the tremendous and overwhelming pressures
that the student will not succeed in obtaining acceptance to
the medical school, that causes the Black student, who is accepted
to feel a special sense of fortune or omnipotence which places
him apart from, not only other Black students, but all other students
as well. The student operates under the delusion that he will
succeed no matter what the odds. Thus, the Black students enter
the medical school with a delusional perception of grandeur that
they are part of an elite special group and that the mere fact
of their existence as medical students is sufficient demonstration
of their ability to make it through medical school successfully.
However, with the results of the first exam, the sense of euphoria
is usually replaced with profound depression.
There is also the phenomenon of reciprocal inhibition sibling
rivalry. This is a condition that evolves when a small number
of Blacks relative to a large number of whites find themselves
thrown together by unavoidable circumstances. The Blacks tend
to form themselves into kinship-like systems. The Blacks, thereby,
can compete amongst themselves instead of with the massive number
of white students ***************the parental-image surrogate

- the medical institution. The white school enjoys the role of
parent over the Black student whom it looks upon as childlike,
anyway. It encourages the sibling rivalry and competition as long
as it remains with the Black sub-group.
The white medical school maintains the division of competition
lines between separate Black and white camps by insuring the whie
studentts will shun the Black students in such a way as to imply
deficiencies and short-comings which engender the attendent problems
of lower self-esteem and expectations. The deprecatory climate
then perpetutes itself when the Black students oblige the faculty
by achieving lower grades than the white students. This cycle
has been termed the Pygmalion phenomenon. 29
The Black students for their part are rewarded for maintaining
the competitive spirit among each other by appointments to various
flunky committees to the assistant to the vice dean in an advisory
capacity. This gives the student co-opted the impression that
he is someone of importance with something to lose if he rebels
against the status quo and gives the school opportunity to create
and manipulate internal conflicts among its Black students.
The ending of euphoria with the posting of the first exsam
grades is usually the nidus of culture shock between the Black
student and the school and among the Black-oriented Black student
- a Black student trained at a Black college - and the white-oriented
Black student - a Black student trained at a white college. Thus,
when the Black-oriented Black student encounters the white-oriented
Black student, they meet each other with a sense of trepidation
and confusion. There is usually the added surprise and frustration
in the white-oriented Black student who find that the Black college
trained Black student has performed better on examinations than
has he. The mechanism for this is thought to be a well established
adoption by Black trained Black students in **** together *******
whatever interpersonal conflicts they might have, while the white-trained
Black student is still retreating into isolation and intellectualization.
As the infra-cultural competition becomes more intense ther
students begin to behave in a manner termed identification with
the aggressor. The students become sado-masochistic upon each
other. This leads to the development of agitated depression demonstrated
by non- nutrional orality - cigarette smoking, alcohol consumption,
pill taking, a phenomenon of hoarding - hoarding of notes, exams,
knowlege of social events, and the evolution of depressive equivalents
chiefly somatization expressed as an increased fatiguability.
In the second year Black medical student, dysfunctional behavior
is a manifestation of identity crisis. In the second year student,
the most profound stresses are exerted upon the students' sense
of self, on the one hand, by the Black community which responds
in an aproach- avoidance manner towards the student - alternately
and concurrently, saying "you're sure a credit to the race, brother"
and "you're just like the rest of them white motherfuckin' doctors."
On the other by the combined forces of hte students internalization
of "detachment behavior" which I have stated is functional in
the white student but which exacerbates the existing alienation
from the Black community, the students increasiong frustration
at trying to be a good [white] doctor-academician and the insensitivity
of the white medical faculty to observe those stresses, empathize
with them and offer positive valid alternative solutions. Instead,
the medical faculty, chastises the Black student for not being
like his "peers" -not acting white enough- and exhorts him to
act in ways that makes the Black student feel even more depersonalized.
If the white student, at this level has fear of leaving the human
race - the white human race - then it should not be at all surprising
that the Black student feels this way as well.
Medical schools, by their internal orientation and by the
orientation of the community that supports them, are established
by, for and of the white-middle class values of the American society.
In the crisis of coping with self-image both the Black and the
white student regress to "good-fellow" stereotypic behavior.

However, in the white studient this behavior is anticipated and
incorporated into the societal folkways in such a way as to fulfill
the dual functgions of giving the white student an activity of
emotional release while at the sane time furthering him along
the road to his degree. Some examples: Dr. Kiley of Marcus Welby,
M.D. fame, can have a few beers wigth the boys, ride his motorcycle
and yet, at the appropriate time, still be the serious academic
folk-hero physician. Cleavon Little, the only regular "Black"
physician on T.V.'s Temperature's Rising, is always, despite his
appellation of "Doctor" the laughing and scratching Sho'-nuff-nigger
whites appreciate, the only other fairly regular "Black" physician
to be seen is "Spear-chucker, M.D." of MASH whose very name denoted
more of his "jungle-bunny" prowess on the football field than
skill as a surgeon. Nowhere is there incorporated into the society
the "good-fellow" Black person who is also a good physician. The
point is that when the Black student falls back on a good fellow
stereotype, he can only do so within the boundaries of activity
imposed upon Blacks by whites and self imposed upon him by other
Blacks through the mechanism of identification with the aggressor.
When Black students wngage in stereotypic "Black" behavior
none of it is anticipated, little, if any, has been incorporated
into white societal folkways to either give the Black student
emotional release or further his career. The Black can be, the
"Guess-who's-coming-to- dinner", Phi Beta Kappa, Harvard-type
but this requires total alienation from the Black community. He
can be the Superfly type- nice car, fine clothes and push a little
dope - just to augment insufficient scholarship funds, of course.
He can be the Stud - Sweet,sweetback type - if Black means super-sexed
then I'll get all the white womens and conquer the white man.
Therefore, in the second year Black medical student, we see
dispacement behavior stemming from identity crisis exhibited as
"incestuous sexual behavior" i.e., medical students becoming involved
with each other denoted as incestuous because everyone's *****
objective in the "family" is to become a doctor, and many mini-affairs
because the last bastion of Black stereotyping is the Blacks'
purported "over-sexuality".
In many ways, third year Black medicalstudents are correct
in their perception that they've crossed the summit of the the
pass. Yet they are deluded in thinking that they're out of the
mountains. In the third year the student receives some small portion
of patient-care responsibility on the wards. This sets the stage
for the onset of role-identity crisis - chiefly a panic-anxiety
crisis. The student who is told subjectively by himself and faculty,
and objectively by test score achievement, National Board scores,
that he is ill-prepared to skim through the pre-clinical years,
finds himself thrust into an environment where to know everything
possible is insufficient.
The third year student enhibits behavior which can be said
to be counter-phobic - the positive white coat and stethoscope
sign - an attitude of grandiosity and euphoria. The student begins
to think expansively and now begins to rap the faculty(oedipal-electra
behavior), ****. The student also attempts to carry his "good-fellow"
behavior onto the wards. There is a counter-transference or identification
with the client and a coincident hostility towards the medical
profession which results in doubts about the career choice-- role
competency-role identity conflict--actual conflict with ward associates
and cross familial displaced aggression with concommitent intrafamilial
displaced aggression.
Familial displaced aggression takes place under the guise
of students having affairs with other students' spouses or significant
others. It is not unusual at this time for there to be overt threats
or occurrences of violence, including murder. The student feels
murdered each day by the "contemptuous probing of attendings,
residents, interns, etc." and bolsters his sagging ego in the
sexual stereotype and desire to kill the system [equally impotent
other students]. I am told by good authority 30 that among students

with children at home, there is an increased thrust toward dominance
over spouse and children. There is special resentment of children
2-4 years of age because the child is moost actively at that age
in competition for the mother's attention.
The overwhelming aura about the fourth year Black medical
student is paranoia. Paranoid ideation, sometimes bordering on
the pathological, that something or someone will not let the student
graduate. The senior year for the white medical student is a time
of "playing Army" 31 putting in one's required time through various
and sundry electives until the degree is conferred.
For white medical students, each day, week, month since his
entrance into medical school has bolstered his confidence in himself
and augmented his knowlege and behavior that he might shoulder
the responsibility of physician. For the Black medical student,
each day, week, month has been an uphill struggle against overwhelming
odds that he demonstrate a minimal quality of knowlege and behavior
which no one expects him to have anyway. He arrives at the senior
year with the most minimal to no reserve to continue the struggle
- a further exacerbation of the ever present role competency-role
identity conflict.
The medical school ever ready to help-you-in-the-worst- way,usually
does, by adding real and imagined evidence to the Black student's
paranoia. Often in the senior year scholarships are cut back or
little to no help in internships is given 32 or small "surprises"
in the form of extremely poor performance ratings are tendered.

Many Black students attempt to cope with the sense of paranoia through therapy within the available psychological counseling avenues. However, even established psychiatrist are attuned to the problems and "reality" of white populations. therefore, the Black medical student finds no succor there and most often a counter transference occurs which drives the white psychiatrist back into psychoanalysis.33

Assuming graduation occurs, the final blow to the Black medical student has been the uniformly poor internship matching program results, the breadth of which is presently being investigated by which unofficially were described as "as expected"34One can only muse that Black consensus that "they won't let you be a doctor" may be true.

Perhaps, the emotional stresses inherent in being a Black medical student resolve when the person becomes a physician. However, when I find in a standard sociology textbook35 the following definition - "Status Inconsistent iis often the result of different rates of upward or downward mobility on the dimensions of stratification. For instance, the Negro physician, is status inconsistent because he has low ethnic prestige and high occupational prestige; - I wonder if its' only the beginning.