It’s difficult for me to judge if my dislike of certain rotations through medical specialties/sub-specialties comes from a genuine dislike of the type of work required for the specialty or if it’s simply a reflection of my dislike for 1) the faculty I work with in the specialty, 2) the specialties’ working conditions, or 3) more broadly the ecology of the healing environment.
faculty as… role models?
The interpersonal dynamic in the emergency department at one particular hospital where I work is an example worth highlighting. Physicians I work with there have been less than welcoming and sometimes even outright condescending toward me. The one that was actually kind to me and helped me try to learn something new during one of my shifts also spent half of the time on shift talking with the other physicians about finances and how big their retirement funds are and/or gossiping about one of their colleagues who I happen to have as a professor (and who I happen to find is a very kind and generous teacher). That dampened my respect for the whole group of them, unfortunately. I enjoy the work of emergency medicine (figuring out what the diagnosis is for any individual who walks into the ED), but the work environment and the personalities it seems to attract are less than appealing.
On a different note, my pediatric outpatient faculty were some of the kindest, most generous, and most flexible physicians I’ve met thus far. They openly valued families (including their own!) as much as they valued their profession, and their priority was always establishing comfort, honesty, and education in their relationship with patients and their patients’ parents/guardians. They were active members of patient advocacy organizations and legal-medical partnerships. They seemed happy in a way that seemed qualitatively different from other physicians I’d met. I admired them.
working conditions
Let’s take part of my pediatrics clerkship as another example. Specifically, let’s examine my week-long rotation in the newborn nursery. I worked in a closet. Literally. When not examining a baby in a patient room or in the incubators of the nursery, I spent hours reading, typing notes, and studying in a closet. The workroom for trainees and students is a 12 ft x 12 ft former equipment storage closet that’s been converted into a workroom. We worked at computers and desks stuffed into a very small windowless space. No better way to go a little crazy when working a 12 hour shift when your home-base is a closet. Unfortunately, the physicians’ workroom is only slightly more pleasant, as it is also an oversized closet with no windows that happens to have soft lamp lighting rather than harsh fluorescent overhead lighting. I think this example is so valuable because it illuminates a small piece of medicine that I find rarely talked about: physicians and trainees as capital. The political economy of medicine is not divorced from capitalism and its exploitative necessities. This is a recurrent theme of my clerkships that likely deserves its own separate post.
ecology of medicine
Ah, and the best example for last: my primary care clerkship site. Now, my primary care preceptor truly deserves a post of his own; I can already see the title of that piece of writing, in fact. It would look something like, “Where the #MeToo Movement Meets Medicine,” and as you can probably guess, it would be an essay about the intersection of mysogyny, toxic masculinity, and the practice of primary care medicine. I won’t launch into a full analysis of my experience right now, but allow me to dive into a few observational sketches regarding my experience. My preceptor is a middle-aged man who operates with many unchallenged assumptions, theories, and “truths” about the world. For example, he believes male ObGyns are better than female ObGyns and will only refer his female patients to male ObGyns. He believes part-time physicians are phonies and care more about going to “yoga class” than “doing something that has merit in the world”; he criticizes people (women) who choose to be part-time physicians in order to also raise a family. He also believes that wearing gloves while examining men’s genitals is a reflection of prejudice on the part of the physician (or in my case, a trainee), yet he purports to always wear gloves when examining women’s genitalia. He also gives unsolicited advice to me about my appearance or about what I should do with my life. And don’t even get me started about me being “pimped” (med training lingo for “quizzed”, “grilled”, “roasted”) in front of patients in their exam rooms that he likes to do…
Beyond these discrete examples of his unchecked beliefs and his own biases, he operates his primary care practice in a cultural milieu that is worth pointing out. His patients are almost exclusively older people aged 40+, and his clinic looks to be straight out of the nineties or the early aughts. I don’t believe this is a coincidence, because he operates under an old-school type of doctor-patient relationship that is ultimately paternalistic and not necessarily keeping pace with interpersonal/political/social advances in medicine. A few examples: He prescribes unsolicited marriage counseling, personal psychological assessments, and life advice to men (and maybe women too, but I’ve never seen that). He tells his patients what to do without establishing the patients’ goals for their health/life, and he operates with full deference and thus without any challenge from his patients. In short, he does not practice shared decision making and he is often not forthcoming with his patients in regard to why he is prescribing certain medications or why he is ordering certain blood tests or radiologic studies. This is a kind of model of “doctoring” that puts physicians in a place of extreme privilege and endows them a font of authoritarian power from which to unceasingly draw. And ultimately it robs patients of their autonomy.
While I have absolute confidence that this particular doctor is operating with his patients’ best interests in mind, I hope to never be like him when I am a licensed physician. I guess that means I’m having a good learning experience at this clerkship site?
Overall, my clerkship experiences thus far have been galvanizing. I don’t particularly like any specialty I’ve seen so far, but not necessarily because I don’t enjoy the work that the specialty entails. I believe it’s due to the toxicity of the environment, culture, and interpersonal dynamics I see in each specialty. I want to desperately do something radically different than all that I’ve seen thus far. Which leads me to a challenge: how will I be such that I will not re-create these problematic patterns in my own practice?
karuṇā 