Those concerned with the way our physicians are trained should run, not walk, to the nearest book store to buy a copy of Melvin Konner's Becoming a Doctor: A Journey of Initiation in Medical School.
Konner abandoned a career as a professor of anthropology at Harvard to enter medical school at age 33. In this memoir of his 3rd and 4th years, he combines a novelist's sense of character with an anthropologist's eye for the ways a professional culture can shape individual identity and behavior.
The result is a thoughtful insider's account of how young men and women with innocent hearts and the best of intentions gradually adopt values and behaviors that render them less and less able to truly care for their patients.
Konner takes the reader along as he and his classmates learn the art of medicine. He alone seems to sense that at the same time they are learning their professional skills, they are also learning to lie to patients, ignore patient concerns, leave patients out of key decisions about their care, and regard patients as impediments rather than resources.
He presents a fascinating variety of medical rogues and heroes. Unlike most of his classmates, he knows enough about medicine and healing to be able to tell the difference. He gives us a chilling portrait of the chief of medicine, a celebrated physician who supervises a suite of laboratories and is responsible for hundreds of doctors in training. He describes this man as hopelessly overextended, distant from his patients and out of touch with his own research. We see this arrogant, self-satisfied gentleman give his students a pep talk in which he trumpets the importance of the doctor's concern for patients—while his own reputation for ignoring patients is legendary and the educational demands of his program are so brutal that the poor students can barely remember their patients' names from day to day.
"Ward medicine—without humane sensibility, without ethics beyond legally defensive medicine—was not anything I wanted to do."
But Konner is not a naive critic out to belittle every aspect of modern medicine. His portraits of the rare good doctors he encounters radiate from the page like a powerful beacon of hope.
The book is full of unforgettable moments, as when Konner watches a conceited and contemptuous attending physician tell a patient he has malignant brain cancer:
It was mid-afternoon and the television was on in the darkened room. Dr. Gerard walked up to the bedside and talked over the soap opera patter.
"The CAT scans are in," he said matter of factly but almost gently, "It's just as we thought, probably glioblastoma multiforme. Not good news, but no different from what we expected."
"Does that mean it is malignant?" Mr. Gianetti asked.
"That's basically what it means. Although it can't be said with absolute certainty without a biopsy." He turned to me and said, "Maybe you can stay here and explain to Mr. Gianetti a little bit more about the findings."
I nodded since I had no choice. To Mr. Gianetti he said, "I have to go to clinic. I'll he back later and we can talk about it some more." He then walked out of the room.
Konner then sits with the stunned patient while he talks about his life: "I heard no regrets, no recriminations, no analysis, not even sorrow, only, 'This is what I did and it was good...’ I felt greatly privileged by the opportunity to witness this accounting of a life and I remembered the advice of the Jesuit priest who had become a psychiatrist, 'The dying are courageous. They will help you help them."'
One can't help liking this thoughtful, concerned medical student, writing of "Nan, the labor nurse, who by her own admission had a 'bad attitude' toward medical students, meaning a low tolerance for their arrogance." Or speaking of a resident who was particularly helpful and kind to him: "He did not seem as thick skinned as some of the others and I worried for him."
Konner was extraordinarily well prepared, and attended one of the best medical schools in the country, so his experiences reflect what happens at the very highest level of medical education.
One can only feel sympathy for Konner's ambitious, narrow, driven, classmates. They go into medicine with such dreams—only to be inconspicuously but gravely brutalized by their training. They venture deeply into the miraculous world of life and death, but they are taught to regard it as so humdrum and mundane that they are unable to benefit from the experience. They remain forever removed from real life, unsatisfied, self-aggrandizing, and vaguely adolescent.
Doctors are so strongly socialized to ignore the dark side of medical practice that few people with Konner's training have the chance to observe medical training from the inside. I must say that Konner's reaction to his medical training coincides exactly with my own. As he observes at the conclusion of his medical clerkships: "I was not at all sorry to move on. The nature and substance of ward medicine—experimental geriatrics with interminable hair-splitting conferences, without humane sensibility and without ethics beyond legally defensive medicine—this was not my idea of anything I remotely wanted to do."
R E S O U R C E
Becoming a Doctor: A Journey of Initiation in Medical School by Melvin Konner, M.D., 1987, 412 pages, $7.95 from Penguin Books, 40 West 23rd St., New York, NY 10010