My Medical Education

By Miriam Garfinkle

I’ve wanted to write an article on my experience in medicine for a long time but never seem to get around to doing it. I’ve thought on and off about what format I’d use, whether it should be “a day in the life” sort of thing or just a treatise on something like women in medicine. The fact is, I’m not sure what exactly I want to say. In some ways I just want it to be a purge of my horrible experiences. I’ve read experiential type stuff of other people who have gone through medicine and it often helps purge me, but I’d like to say something to my non-medical friends as well and not just evoke the response “poor thing what a terrible time it must have been.” It really is the story of the socialization of a profession which in today’s society wields a great deal of moral if not true economic power and it was interesting to go through that, and painful, as a leftist and as a woman.

When I first entered medical school I remember coining the expression for myself “double thinking.” By this I meant I was never fully saying what I believed, that my thoughts and feelings were racing deep inside me but I was never letting anyone else know them and often saying things I didn’t quite believe. I had done this of course in many situations in the past were I was confronted with an opposing ideology to which I was forced to submit for one reason or the other, e.g. job. But I never remember feeling it so acutely as when I became a medical student. I think one of the reasons is that I went to a very “liberal” medical school which fairly radically differed in its method of teaching to other traditional medical schools. It also gave voice to a number of humanist concepts about practising medicine, treating the patient including the “psycho-social” aspects. And even though the idea was very much to treat the individual and gave little consideration to changing the social environment to improve the health of individuals within it, there was the opportunity to discuss to some extent, social aspects of disease. At the beginning, therefore, I was seduced into a feeling of semi-comfortableness in this liberal school. It ended fairly early on, when in the first couple of weeks I was invited with my fellow students to my doctor tutor’s house, his mansion rather, complete with outdoor swimming pool and realized that the most important aspect of my ideological training was not whether I though industry caused disease, but that whatever I believed I should identify with my profession and never do anything that would harm or threaten its privileged position in society. And so began the double thinking, because, as it was verified to me over and over again throughout my schooling, there really is so far as you can go in such a liberal environment and then you reach a dead end. And in such a school the social pressures are enormous. I mean, if out of five people in your tutorial group, you consistently don’t appear when your tutor invites you for dinner or whatever, you become quite conspicuous. If when you get there you casually challenge the basis on which he has acquired his social status, well that really wouldn’t do either (or at least I could never pull it off – maybe I’m a coward, but he’s also the guy who marks you.)

And so I kept pretty quiet. And there were a few in my class who felt similarly, who also kept quiet. The vocal ones, the ones who were on the student organizations fighting for changes within the school were usually of the same breed as their establishment doctor counterparts, wanting to improve the education of the profession but never once considering “deprofessionalization.” So because those of us who thought differently were pretty quiet, it delayed us getting together, finding each other for awhile but we did eventually, became friends but realized that our real activities for change would have to start when we were free of medical school. It was those people who kept medical school for me, from being completely unbearable, and allowed me to “think” again instead of “double think” all the time.

Being a woman in my class was rather a unique situation for a Canadian medical school. We were the majority or almost – out of 100, 51 were women, which then dropped to 49 because of a couple of drop-outs. The main reason for the switch-around was because I think, of the selection process at the school which favoured verbal, “sympathetic” type people involved in some way in social-type services, a role very familiar to women. So I looked around my class of 100 and was comforted in seeing 50 other female faces. (The fact that they were also almost all middle class W.A.S.P. faces is another story, because the verbal articulate individual they wanted also discriminated against racial minorities more than in other medical schools and of course class discrimination is universal.)

Despite being among so many women students I don’t remember having one woman teacher, tutor or clinical skills instructor in my undergraduate training. However, the real impact of sexism took place I believe, after I left the relatively protected situation in medical school, and faced internship, which I will tell about later.

There were two aspects of the women in my classroom – one good and one bad. The good thing was that I found among the women in my class, people who were more likely to put their personal lives and goals above the “calling” of the profession. They wanted to have and maintain relationships, not martyr themselves to their jobs and if this meant a decrease in status (and income), they accepted this. (One may be cynical and say that this is because they are middle class women who are only supplementing their partner’s income but this was really not always the case at all. In fact in my class, 3 women had babies during the course of our training and it did not exactly enthrall directors of the program as a precedent. Most of these people were not what I’d call “radical” at all but rather just plain decent and humane and I was more likely to find such a person among the women (there were the odd men like that) and there was a far greater percentage of these type of people in my class than other medical schools as far as I’ve heard where the percentage of women is much lower.

The other aspect was a woman like P.J. I have never been so intimidated by anybody in my medical school as this woman who was in my tutorial group. Ambitious, fiercely competitive, straight out of phys. ed., she reminded me that the dominant struggle of women in medicine has not been one with which I identify i.e., emulating masculine qualities and simply striving to fit in equally to a male world. For that reason, I have never gotten involved in any way with “the women’s chapter” of the medical association. That kind of mixture of professionalism and feminism leaves me cold.

I could say more about medical school itself but I think I’ll leave it at that. The main struggle I think was against the seduction of “you’re one of us now and we have common interests” and if you stayed cleared of that, you were likely to stay clean. And I must say my affiliation with the few in my class who also felt as I did, plus my continual involvement in leftist activities outside of medicine, really helped keep my head clear. Medical school itself was really benign compared to the nightmare of internship and in fact the methods for learning in my medical school were the most humane and reasonable I have experienced.

The main thing I think to relate first of all, about internship is the ambience. Picture yourself thrust in an old dark downtown hospital where there are really sick people with all the smells that you have always associated before with medicine, pain, sickness and needles. (and my own mother died in an intensive care unit). You are now expected to make a complete emotional turn-around – you are the one who orders the medicine and needles and it is on you that these sick people depend because of your 3-odd years of training. Add to this enormous sudden load of responsibility, that you are constantly fatigued because one night in three (see footnote) you are awakened several times a night to do a variety of tasks. One of these may be to reinsert an intravenous into someone’s vein which is necessary because the person is unable to take anything by mouth. The hospital used to hire special nurses to do this at night but it is cheaper to have interns who are paid a fixed salary anyway, to be simply woken up. and since you are a beginner and have never really been taught how to do it properly, you are more likely to cause unnecessary pain, especially the first few times and especially if you’re into your 24th working hour.

There are other more “real” doctor tasks to do like see a patient who has pain in the chest or admit a sick patient to hospital in the middle of the night. And there is another role to fulfill, if you have any heart at all. While inserting the I.V. or seeing a patient for a headache who wants an analgesic, they may need more than a technician or diagnostician and need to make conversation or pour out their heart about their fears of death, real or imagined. For example, I’ll never forget this one patient. I think her name was Lucy, a young black woman of about 35 with leukemia. I was called to see her to start an I.V. at 3:00 in the morning. Most patients are pretty drowsy and out of it of course at that hour but she was sitting upright in bed, had all the lights on, alert and seriously anxious. She grabbed me around the neck when she saw me and cried her heart out (I had never seen her before in my life.) It was impossible for me to go back to sleep that night because I was so disturbed and of course I was expected to function fully the following day. And it certainly is not the sort of thing which your consultant would understand (You might impress him and gain his sympathy if you said you were assisting emergency surgery all night).

On the other hand, it was often my patients who offered me the sympathy and comfort when I made my all night vigil. The kind of old ladies who say “oh dear, you must be so tired” do a lot to keep you going. Very few, however were aware of the hours you worked although they knew they saw you a lot. I certainly wouldn’t want anybody making decisions about my health with the little sleep I had.

And so the good little intern is a little cherub working in the day, heeding the orders of a usually domineering demanding consultant, creeping stealthily in the night, forever patient, kind and efficient. But in reality what happens to your head is quite different. You hate your consultant and your situation but you start to take it out on your patients, they become your scapegoat. I began to resent their complaints, and found myself wondering who was more fatigued, and worn out, they or I. Especially in the middle of the night on call, I found myself thinking some incredible thoughts, like I hope Mrs. so and so doesn’t die on my night on call but I hope she does die tomorrow then I won’t have to worry about her my next time on call. I couldn’t believe I was thinking these things. They were never fully formulated or articulated or of course acted on, and these thoughts are not unique to myself but are shared by many of my other intern friends in their most fatigued hours, regrettably so.

A word about hospital hierarchy. Of course there is a definite one with hospital workers on the bottom and doctors on top and nurses somewhere in between. Even though you are probably one of the most exploited in the set-up as an intern, you will by virtue of your street clothes, white lab coat with the stethoscope hanging out of your pocket, are on the top of that hierarchy. In a large institution such as a hospital, it is very difficult to break down these well defined roles by anything but by token gestures or by being as friendly as possible to fellow hospital workers. Just as an example, I was once standing with a group of doctors making “rounds” on the patients (that means going to see the patients one by one as a group and discussing them). A woman worker wanted to enter the room to clean and the doctors just ignored her, and she was too intimidated by the group of white coats to ask them to move. I interrupted the discussion to tell them to move for her, they looked at me annoyedly for interrupting such an important discussion and she eyed me gratefully as she entered the room. From then on, whenever we saw each other we smiled warmly and knowingly. Most of the time though I was so busy surviving myself, I had little time to worry about the plight of what is a very lowly paid and exploited group of workers. My relationship to nurses I’ll mention briefly – they are the people you work with the most closely. In my hospital especially – in most hospitals there is not even lip service paid to a concept which was spouted in my medical school, the team approach – i.e., working together on patient care. Nurses, I found, excluding nurses aides and assistants, are a heavily “professionalized” group, i.e., very conscious of their role and status, especially concerned with differentiating themselves from lower status roles like nurse’s aides, both in terms of wages and also in terms of what they would not do as nurses. On the other hand, on most wards, they were a overworked lot, often frustrated with what they weren’t able to do in terms of meeting broader needs of patients. As for my relationship with them, it very much depended on the personality of the nurse. Many offered me support and became my personal friends. Others were much a part of my exploitation.

The sexism of internship is a complicated thing for me. There is the obvious blatant chauvinism which exists mainly in the form of sexist jokes and comments about patients, nurses, and women doctors. (I was sheltered from this to a large extent in my undergraduate training because of my majority position and the liberalism of my school. There are horror stories of sexist comments incorporated right into the formal teaching of other traditional medical schools.) One deals with those comments in a number of ways but mainly with repressed anger and a “double-think” if it is dealing with comments from your consultant or a person in authority, a shrug or conspicuous absence of laughter at a sexist joke. The full impact of sexism in medicine is far more insidious, and more difficult to see. It’s taken me a long time to realize how it has fully affected me. A large part of learning in medicine, particularly during internship, is (sorry folks) trial and error. The famous motto is “see it one time, do it one time, and then teach it.” This applies to actual physical skill, like putting a needle into someone’s abdomen to drain fluid (parecentesis) or treating someone in shock. You do get supervision but you are really not thought as well of, if you ask for too much. This kind of “daring” mentality in internship, is, doing something that you are not 100% sure of, is what separates the “boys from the men” and what I think really separates “the men from many women”. The women I knew anyway, and myself, were insistently asking for more supervision than the male interns about things they had just as much experience in. It really is an ego trip (and I think a male ego trip) to say you did so and so many pleural taps (putting a needle in the peural space of the lung for fluid) or treated “so and so many bleeding ulcers”. (notice you treat the case and not the person). And not only do your consultants respect you if you “dare” but the nurses (the large majority) also respect this mentality. They want a doctor who is decisive and active (even if he doesn’t really know what he’s doing and in just putting on a good show). It is really a difficult situation because, strange as it may seem, if you have a lot of confidence in what you are doing, you will likely succeed (a self-fulfilling prophecy). So if you sort of fall behind, because not having that initial “daring” confidence in yourself, you do not acquire as many skills and you begin to lose ground and develop a still lower self-esteem. And I think this is the spiral of many women I know in my internship, they all thought, most of the time, that they were bad doctors.

That is largely of course because they are forced to masculinize when they work in the highly stressful environment of the hospital which is 100% curative oriented. Take us out of this environment (and there is little chance to train at all outside of hospitals in Canada) into a more preventive primary care area, and we are much more comfortable. The problem is when I did get a chance to do the things I felt more secure about, I was so washed out and “unconfidenced” from my hospital work, it was difficult to function at close to my capacity.

So really what happened to me during internship was the culmination of a few different processes. First of all, because I was never “properly” doctorized, ie., professionalized during medical school because of my own ideology, I entered internship in a relatively unprotected position. Roles really do define limits for involvement with the personal aspects of your function. Also, if I had been properly doctorized, I would have identified with my consultants, and valued their judgments and expectations. I would have considered internship as most interns do, as a necessary experience, maybe not a pleasant one, in obtaining my future status I would obtain. I knew I would never work in a hospital setting and the whole health care system of which I was an instrumental part, most times felt incredibly absurd. In fact my whole year of slavery to this system and my own exploitation was absurd to me and the only thing that gave me any reward was my personal contact with patients. My friend, a women, and I used to kid each other. If we had a good day, it was never because we diagnosed this or that we were told we did so good a job, or “saved” somebody’s life (you never really do). It was always because a patient said they liked us in some way or other. But that reward did little to compensate for the hours and agony.

* In case you are not familiar with “on call” terminology – “one night in three” – means you work for e.g. Monday all day 8-5 and then you must stay in the hospital all evening and night for “emergencies” and other things, and then work all day Tuesday and repeat this every three nights.

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