The American Journal of Bioethics 4.2 (2004) 52-55
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Socialization in Medical Training:
Exploring "Lifelong Curiosity" and a "Community of Support"
Deborah L. Kasman
I am grateful to Delese Wear and Mark G. Kuczewski (2004) for raising concerns over the state of professionalism curricula in medical training. Despite white coat ceremonies, ethics classes, and efforts to measure performance in professionalism (e.g., communication with patients, ethics knowledge, and team building), something within the academic environment continues to circumnavigate complex dynamics. The "hidden" curriculum within this milieu has allowed cynicism to grow, abusive behaviors to be tolerated, derogatory comments to be accepted as stress relief, and self-interest to flourish. Despite attempts, unraveling the hidden curriculum remains elusive. Recognizing that the practice of professionalism continues to thwart the goals elucidated by the theory of professionalism (Ginsburg and Stern 2004; Jecker 2004), I want to explore practical behaviors that could impact medical training.
Socialization in Medical Training: The "Dark-Side"
I will briefly describe a model of socialization that I've developed to encapsulate the "dark side" of medical training. It is intentionally exaggerated and one-sided in order to exemplify issues currently understated in pedagogical literature. It attempts to illuminate detachment and unprofessional behaviors manifested after students step through the idealistic gates of medical school (Coulehan 2001).
In their first year of training, medical students join a class of 150-200 compatriots, who become their new family. Long hours of classes and the rigor of study frequently [End Page 52] manifest in separations, loss of prior relationships, isolation, and even depression (Christakis and Feudtner 1997). In their first year, students are also presented with a corpse for dissection. This ritual represents a "rite of passage" separating students from others who have only witnessed dead loved ones or never even seen a dead body. This passage stimulates anxiety and detachment for many students (Charlton et al. 1994; Nnodim 1996).
Third-year medical students are presented with the "short white coat," a symbol of their subservient status on the team. This physical symbol is frequently reinforced by actions reiterating that clinical students are to "be seen and not heard." Students recount stories in which they were never asked their name on new rotations, were not oriented to the wards, were not given lockers or told the locations of bathrooms or phones. One older medical student, who had been a confident professional before medical school, stated that he did not know how it happened, but when he donned the short white coat, he became tongue-tied and unable to express himself in this environment. Hence, third-year students can feel "stripped" of their prior identity.
Fourth-year medical students regain confidence, purposely bolstered and given authority as acting interns. Graduation day is magnificent. Students receive many pats on the back, for now they belong to the club. Unfortunately, internship deflates these feelings with long hours and grueling responsibility for the lives of extremely sick patients. Signs of depression and burnout are rampant (Shanafelt et al. 2002). One could argue that many interns show signs of post-traumatic stress disorder. Although this might seem an exaggeration, for many, internship is a difficult and frequently traumatic experience.
The previously-eager entering medical student has been now isolated from his or her roots, stripped of prior identity, enlisted in the club, and then exhausted or even traumatized. In the last two years of residency, she or he is built back up as a success story, having joined the profession of medicine. She or he has been socialized to the attitudes and nuances of acceptable professional behavior.
Socialization in Medical Training: An Alternative Model
All professionals are socialized; this is a truth of process. Unfortunately, current medical socialization seems to diminish curiosity about patients' lives and the impact illness has upon their dignity. Medical students feel closest to patients and enjoy intimate details of their lives via extended histories. Interns and residents, faced with severe time pressures, try to herd patients through, abiding to lists and protocols for care...