Heart Failure - A Cut Below the Rest

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


II. SURGERY - September 29-December 19

A Cut Below The Rest

I saw the stars this morning on my way to my first day. Gray clouds on black instead of white on blue.

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I talk to classmates who just finished surgery. One cried every night for two weeks. Another told me it "destroyed" her. My residents (am I "their" student?) overheard one classmate describe how she came out of the surgical rotation oral exam crying. They laughed.

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Pediatrics took from me sleep and food. Surgery takes drinking too. It's a four hour surgery; you can't just leave to pee.

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Surgeons have little lenses attached to their glasses in the OR; it gives them a narrow view of the world. At least they wash their hands.

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I am daily shocked at the distracted, unfeeling, unconcerned attitude of those who work with the sick. Whatever pretense of humanity medicine ever had is lost in surgery. I empathize with my poor brain which struggles in dreams and awake to make sense of it all. My latest dream was of a heavily armed gentleman who went around killing doctors, showing up at meetings with machine guns.

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When we hit the third floor today and everyone else got off the elevator, the resident lamented that all the chicks were gone. Later that day a surgeon remarked that he'd rather be working with the "cute intern."

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We were lectured about the advantages of breast milk this morning!

It seems that it comes in good-looking containers and one can play with the empties. Surgeon to surgeon. The head of the department laughed and so the fellows*, residents and interns did too. He makes sure to add that it's good that there aren't any women around.

* Fellows are between residents and attendings on the ladder - they still look longingly up at the butt of the attendings, but can shit on the residents below.

The whole profession seems to hold a similarly enlightened attitude. In the early 1980's the American Society of Plastic and Reconstructive Surgeons suggested that small breasts be considered a disease - they named it "micromastia."

A medical student got an article published in the Nation:

The prevailing attitude towards women was demonstrated on the first day of classes by my anatomy instructor who remarked that our elderly cadaver 'must have been a Playboy bunny' before instructing us to cut off her large breasts and toss them into the thirty-gallon trash can marked 'cadaver waste.'[31]

According to an article in Technology Review, this is a common phenomenon. Medical students are routinely instructed in anatomy courses to cut off the breasts of their female cadavers and, without examining them, toss them in the garbage.[32]

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Surgery does bring me back to the scalpeled days of anatomy. My mind flashes on an image of a face flattened against a metal table, nostrils in a chemical puddle. I lost a bit of my humanity every time I walked in there.

Students first encountering gross anatomy - Appendix 11a.

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Pio Baroja (1872-1956) on his deathbed:

Pio Baroja, a foremost Spanish novelist, graduated from medical school at the end of the last century. After substituting for a village physician for a few months, he quit medicine forever, becoming a prolific novelist.... For over 50 years of literary life, he had nothing to do with medicine. Just before he died at the age of 83, he went into a coma, waking only occasionally to scream in a frightened voice: 'I am going to fail the anatomy exam! I am not prepared.'[33]

"Learning" in the first two years has its own traumatic intensity. See Appendix 12a.

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Book title The Doctor: Father Figure or Plumber.[34] Alternately, doctor as ego-driven "morally neutered technician."[35]

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Thinking it would be the smoothest transition, I start on the pediatric surgery service. The head of the department has a big autographed picture of George Bush hanging behind his desk. Also, a picture of a fish he held by the gills; 40 pounds, he tells me, 44 inches. He also has a poster-sized picture of his own house.

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Ironically the most healing I did all day was to squeeze the arm of a classmate being beaten down. Everyone's miserable. The whole mentality is if I can't sleep, if I can't have spare time, neither can you. One resident confided in me that she felt real hatred walking home in the morning as she watched kids running around, people smiling. A real hatred, she repeats.

The interns are the sickest looking people on the floor. As the interns experience the worst time of their lives, they forget that it's probably the worst time for the patients too. The same my-life-sucks-so-yours-should-too attitude towards medical students gets directed towards patients. The roots of the word compassion mean "suffering with," but the interns just suffer alone.[36] I bet that my surgical intern could be hospitalized for depression.

Suicide and depression in medical school. Appendix 13.

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During the first two years of medical school there is a constant gnawing at the brain that says, "I shouldn't be enjoying life I should be studying." During third year it changes to more like "I shouldn't be eating lunch I should be studying."

Where is the Life we have lost living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge lost in information?
- T.S. Elliot

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I am surrounded by gunners gunning.*

* Yet another militaristic term in medicine. "Gunner" is used to describe students - usually those with a future in surgery - who place grades above all else.

DEGRADING

"If I were asked to enumerate ten educational stupidities, the giving of grades would head the list.... If I can't give a child a better reason for studying than a grade on a report card, I ought to lock my desk and go home and stay there" - Dorothy De Zouche.[37]

Krishnamurti:

The function of education is to eradicate, inwardly as well as outwardly, the fear that destroys human thought, human relationship and love. The function of education is to help you from childhood not to imitate anybody, but be yourself all the time. You may learn to... pass all your exams, but to give primary importance to these superficial things when the whole structure of society is crumbling, is like cleaning and polishing your fingernails while the house is burning down.

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It's not even about caring too much about grades, this self-deprecation. It's caring too much about what others think of you. Further, it's caring at all about what people for whom you have no respect think of you. Hating is the easy way out.

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I now know why sleep deprivation is part of torture. I fantasize about sleeping. I hate that the idea of getting up as late as 6:30 is like a dream.

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I am not fulfilled. I am becoming a dull boy - all work and no play. How much self-respect must I have to treat myself like this? I demand more. What am I going to do about it?

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Violent yelling put-downs. There always seems to be someone lower to blame and always someone above to cover for and cower from. I hate it when we have a patient named Michael. Whenever I hear my name in rounds my stomach sours like cold spinach.

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I feel the need to ask permission to go to the bathroom - like in third grade. I don't like thanking people for granting me time for lunch. They like us both - student and patient - deferential and self-degrading. And I see it every day.

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Nurse: "This patient is so awesome; she doesn't complain about anything."

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It is much more important to know what sort of a patient has a disease than what sort of disease a patient has - William Osler

Patients are often referred to as either diseases or as procedures (the appendicitis in 214 or the appendectomy).[38] Typical patient-as-disease quotes from the floor: "What's that hernia's name?" "Did the gallbladder go home?" "Lip's mother wants to talk to you." "Is the stab wound here?"

One sociologist writes:

Much of the language used by the house staff* to describe patients went well beyond the affectively bland process of objectification to become an evaluative language of disparagement and, at times, intimidation.... The use of pejorative slang terms and sarcastic black humor is virtually universal in the U.S. house staff culture and was abundantly in evidence in the settings I observed.[39]

* "House staff," meaning interns and residents.

Internet list: You might be in the medical field if... You find humor in other people's stupidity.

WHITE AND DARK MEAT

I count the number of faculty who refer to people as GOMERs (derogatory term Get Out of My ER). If they're not GOMERs, they're "low-lifes," "real kooks," one's a "slug," a "fuckin' nut," another a "fatty." This one's first name is, "spelled like a fag."

Gastric bypass patients are "whales." Can you smell the POOB? The surgeon asks. Putrid Odor of the OBese. Many of the insults and crude remarks are directed at overweight women. In one study of medical student perceptions of patient problems, the strongest negative reactions found were to the prospect of treating patients who were described as obese. Noted as an aside in the study, students who were primarily interested in the accumulation of wealth were found to have a greater dislike for treating obese patients.[40]

Sociologists studying house staff culture note that "scumbags," "garbage," "junk," and "SPOS" (Subhuman Pieces of Shit) were terms repeatedly used to characterize patients, sometimes even within the earshot of patients.

From the New Physician:

Mexican-American women who cry out in pain during childbirth are not women but 'Ai-Ai's.' Old people with failing bodies aren't people, but 'PPP' (Piss-Poor-Protoplasm). Patients with unpleasant or uninteresting diseases are not human beings, but crocks or turkeys.[41]

Virtually all students - between 96 and 98% depending on what study you look at - reported having heard patients referred to in a derogatory manner by physicians.[42],[43] "Indeed," one doctor writes, "using this language is one way of becoming... integrated, one way of showing residents and fellow interns that you are a team player."[44]

From the medical literature: "The undesirable patients were everywhere - those who were poor ('dirtballs')... [those] who knew too much about their disease ('manipulative'), or too little ('ignorant')...."[45] "So extensive and contradictory was the range of uninteresting and despised patients described by so many house officers that one wonders whether there is a truly welcome patient."[46]

I do notice that in some charts patients are described as "pleasant." Today in rounds I picked up on the common thread; they were the smiling Uncle Toms who felt they weren't worthy, who didn't feel the doctors owed them anything, who apologized for their pain.

Good patients and problem patients, Appendix 14a.

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On my first weekend off, someone had to remind me how beautiful the day was.

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The surgeon is using a special suturing technique that minimizes scarring. "I wouldn't do it on a male," he says, "but girls don't handle scars well."

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No, E coli is not the most common bacteria in the gut. I am told that is, in fact, the "dumb sucker" answer. According to one study, over 90% of medical students in their fourth year report being belittled and humiliated in medical school.[47]

In Appendix 15, the art of "pimping" - the constant barrage of questions imposed on students and interns.

No one ever blames the school, the training, the teachers. If you don't know something it is your fault. You are either stupid or lazy. If only you would have worked harder or listened better. It is always your fault.

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From anthropology to exobiology. In pediatrics I was lost among a new culture; in surgery I am among new life forms.

MOTIVATION THROUGH DEPRECATION

I am in awe today of Dr. S - . He is cartoonish in his caricature of surgeon as football coach/drill sergeant. And he hurt us. We were pitiful we were told; we should be embarrassed. "If you come unprepared to my lecture again I will kill you," he said. He would laugh and belittle and sneer at wrong answers; we are in big boy's school now, he would say. When he shouted that I was inane, tears came to my eyes. I wanted to yell out "I'm not nothing!"

Dr. S - has that special mix of the school-yard bully - insecurity, immaturity, and intimidation. Human beings like Dr. S - sicken and sadden me; he must be one of the most unfortunate people I have ever met. If I could relive the day I would relish to have the courage to say, "Dr. S, you need love. Can I give you a hug?" Looking back, I hate the fact that I wanted to know the answers to his questions.

Medical student abuse is one of medical training's dirty little secrets. Appendix 16.

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Thankfully I had to go to court today. Off probation; case dismissed. I remember when we were sentenced I looked forward to getting arrested again in six months and a day. Tomorrow.

This life is not a joke
You must take it seriously
Seriously enough to find yourself
Up against a wall, maybe, with your wrists bound.
- Nazim Hikmet

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When Boston Chinatown smells good, you know you've been in the hospital too long.

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A friend relays her surgery experience to me: "I'd rather have someone wink and be nice to me than yell at me."

Sexual harassment in medical training - Appendix 17.

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A patient refuses surgery. The frustrated surgeon is told to keep his pants on.

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A five year old girl lays naked and unconscious before us on the operating table - legs frogged open - while the doctors comment on her body. She's cute, the head surgeon says. Fourth generation Baywatch, says the anesthetist. The nurse adds knockout and heart breaker. Another surgeon: "But I'd operate on her even if she wasn't so cute, that's just the guy I am." Everyone laughs. I haven't laughed for two weeks.

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The surgeon ends his orders to the scrub nurse with "my sweet." She and I share in the disgust.

Being a nurse must be like being an eternal medical student. Appendix 18a.

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I am asked by a classmate in the hall how I'm doing. I'm OK, I answer. She doesn't realize that I haven't been just OK for years, I've been happy. I live a life of I-was's and I-used-to-be's. As one medical student wrote, "I feel starved, of real life, of whole people, of less questionable work."[48] It's October now and the leaves are falling.

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My favorite top ten list difference between medical school and hell: "People smile in hell." The upturned Autumn crescent moon was the only smile I saw all day.

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Survival mode is not about living day to day; it's about living in the next five minutes. Unable to relax, I eat my supper standing up. Pacing with my soup.

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A resident messed up in surgery today. The surgical attending explained why this was bad, "Sure, this guy's homeless, but this may happen to your brother, who's a person."

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A baby on the floor with liver failure looks like a little yellow Buddha. The infant has been in the hospital all the months of his life, yet no one is treating him. The surgeon remarks that the fact that the family is on welfare doesn't help. A consulting physician exclaims, "Boy, he's a monster." He looks around. "I'm glad the mother isn't here."

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I don't like that the nurses say buttocks when I'm standing right there and butt when they don't know I'm listening.

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I WILL NEVER FORGET JACOB

I held him down on command while he screamed. We were late; the pain-killer had worn off. We gave him more, but started in long before it could have possibly taken effect. A child's suffering sacrificed for convenience. I see it routinely.

The surgeon keeps telling him to relax - to relax as they hook an endoscope into the back of his throat through his right nostril. The nurse has to keep gagging him to suction out all the blood from his mouth. A teddy bear is shoved in his face while the surgeon calls him buddy. "Relax," he said. "Relax, buddy."

And Jacob will never forget me.

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My feet are swollen from standing all day amongst bloody gloves and the smell of cauterized flesh. Snap crackle pop.

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I clutch my clipboard like a shield, mostly to ward away the feelings of the kids in the beds as we round through their rooms, a parade of white coats. Knowing they will be ignored, some of them don't even look up; they just stare off into space. From an article entitled "Struggling to Stay Human in Medicine": "We don callousness like a suit of armor... a breast plate over the heart, a helmet whose visor falls across the eyes."[49]

The author of "Struggling to Stay Human..." recalls a scene from medical school:

During our sophomore year, our class was given a lecture by a research clinician. 'Good morning, patient lovers,' he began.... Ever so often he would pose a difficult question. When no answer came, he would ask, 'Well, if you're so smart, patient lovers, how come you don't know the answer.' The most obvious implication of the phrase 'patient lovers' was that our native compassion was really a phony subterfuge for laziness and ignorance.[50]

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Only when the resident appealed to the attending's eagerness to teach a procedure did the child receive a nerve block as they crushed off his foreskin.

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A fourth year gave me good advice for third year. She told me to never expect to get out early. Never say done.

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Every night I start eating supper after my bedtime. Coming home is like doing triage. It's always getting late.

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A classmate tells me she's been diagnosed with cancer. We were both in the hospital, but she was the one looking up and I was the one looking down. What kind? I ask. How do they treat it? I scanned her for signs and symptoms. Was it papillary or follicular? What's the prognosis?

Oh, I'm really sorry you have such a terrible thing happening to you. OK, bye. Same way I treat all my patients. She learns that there are no ICU beds available - she'll have to wait another week before ablation therapy. I did notice she was crying, but I saw her in the medical model and part of me envied her four day weekend.

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TESTING THE WATERS

Thousands of Americans have already been killed by nuclear weapons; I hope my classmate won't be one of them. From an article in JAMA: "The U.S. National Cancer Institute estimated that the release of Iodine 131 in fallout from U.S. nuclear test explosions was by itself responsible for 49,000 excess cases of thyroid cancer among Americans." Another study estimated that the radioactive carbon, strontium, cesium, and plutonium released worldwide would be responsible for 430,000 cancer deaths by the year 2000.[51]

Medical journals continue to publish articles on the threat of nuclear holocaust. See Appendix 19.

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At times I'm more ashamed by what I don't do. A classmate is failing, falling behind. He keeps getting yelled at for being late to rounds; he has no car and can't get to the hospital early enough. I left him at the hospital today, perceiving my life constricting about me. Will I drive him home tomorrow?

In one Canadian survey, 3 out of 4 medical students felt that their teachers did not try to understand students' difficulties or try to support students who had difficulties.[52]

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I bang handrails on stairs to see if I can still make noise.

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A child is scolded by the head surgeon, "Why are you crying. Why are you crying. You don't need to be crying." And then my personal favorite, "If you stop crying I won't use needles."

"As a child psychiatrist," one doctor writes, "one of my missions in life has been to teach medical students that children have feelings."[53]

From Ernest Hemingway's "Indian Camp,"

'Oh, Daddy, can't you give her something to make her stop screaming?' asked Nick. 'No. I haven't any anesthetic,' his father said. 'But her screams are not important. I don't hear them because they are not important.'[54]

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Surgery as fraternal brotherhood. In fact, the American College of Surgeons motto (translated from Latin - of course) is "Skill and Healing Through Faith and Brotherhood."

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If the colorectal surgeon doesn't manage to sneak in a joke about Greeks and their anorectal problems, he makes sure to make a comment about the South End.* With infantile Limbaugh rants about welfare and immigrants and political correctness, doctors have just simply lost touch with the reality of life for those they treat.

* The South End is a predominantly gay area of Boston.

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A resident is chastised in the OR by a surgeon for "tying like a homo." Interest-ingly, a study found that, in general, when either male or female medical students deviated from traditional gender role expectations - males low on masculinity and females low on femininity - they were more likely to be abused in medical school.[55]

Homophobia is rampant in medicine - Appendix 20.

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FYBIGMI

An interesting medical anthropology article analysed a FYBIGMI theatrical, put on by fourth year medical students. The transitional time between receiving internship placement and graduating affords for the first time in years a short-lived freedom from, "evaluation by, and obligation to, those in authority," hence the name Fuck You Brother I Got My Internship. The authors of the article describe medical school as, "a process of initiation constructed and experienced as a series of increasingly difficult, often intimidating, if not debasing, trials.... What is important here is the recurring pattern of intense intimidation and humiliation."

A verse from one of the skits (sung to the music of the Beatles' 'I Am A Walrus'):

Gave a case at M and M [Morbidity and Mortality conference] where all the other surgeons laugh at me. (ho, ho, ho... hee, hee, hee... ha, ha, ha); In my pants I shit while they laugh and curse and spit all over me. I'm crying.[56]

Of course it should have always been FYIGMSR. Fuck You I Got My Self-Respect.

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It doesn't surprise me that none of the doctors, residents, nurses, or students are black. But all six of the department housecleaning staff are.

Racism is another prevalent problem in medicine. Appendix 21a.

One nurse to another. "Amistad - I mean, get over it."

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Groin, armpits, hair, face - perfecting the three minute shower.

I brought new soap today so that the smell of the soap I used in Maine wouldn't take me back. But I can still listen to the music I held on to there and it just makes me glad I'm home. Stinky eucalyptus will be my 4 a.m. never-to-be-used-again surgery soap.

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The surgeons wear tight green masks on their faces. The nurses often wear the blue ribbed half-bubbles. I wear the duck mask and sneak smiles beneath it.

I preciously guard that smile. Something they will not and cannot take away. I will not offer myself as a sacrifice on the altar of medicine.

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It's been three weeks. Time does move. Nine more to go.

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An Email I got today from a premed was appropriately titled, "Crawling over broken glass in a pool of lemonade."

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The problem with getting up before dawn is that one never knows the countdown. Waking up in darkness I compulsively grab for my watch, four hours or two minutes left? What if it beeps while I'm reaching?

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Last night coming home I snatched a dying leaf from a tree and ripped its veins out.

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Four-thirty in the morning I sit on the edge of the bed, my hand on Susan, watching the clock. T minus. She rouses awake and reminds me it's our anniversary.

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I pass Dr. S - in the hallway and greet him and smile. He doesn't even look at me. The condescension hangs in the air.

I've figured out where I remember the emotion from; it's the same welling rage and powerlessness I had experienced with the police, that same irrational authority.

The first principle of nonviolent action is that of non-cooperation with everything humiliating - M.K. Gandhi

The worst three weeks of the year start Monday, so does my nonviolence training. General surgery and Dr. S. My opportunity to break from fear, to put to rest my adult-child groveling submission routine. Yes sir; no sir. Would I allow myself to be abused by anyone else in my life like this? Or would I refuse? After 25 years you are no longer a grown-up. I've grown up. Justify your authority. What kind of person are you? You're just like me.

From Butterfly to Bird

No longer
pushed
by opposing winds.
Lifted.

For other student's poetry see Appendix 22.

Hatred is the coward's revenge for being intimidated - George Bernard Shaw

Nonviolence is not about reaching out (implication: down) to help the person beating you. Nor is it making excuses for him or her. Nor is it about passive aggressive jabs like my fantasized hugs and love proclamation. It's about being fully present and respecting that person, as a person, with open arms.

Irene reminds me hurt people hurt people. As Longfellow said, "If we could read the secret history of our enemies we should find in each man's life sorrow and suffering enough to disarm all hostility." From Patch's last postcard, "Be kind to those that fight you."

Whoever fights monsters should see to it that in the process he does not become a monster - Nietzsche

What would Gandhi have done? I cannot allow to offer Dr. S - power over me. Immanuel Kant: "If man makes himself a worm he must not complain when he is trodden on." I hope to be thankful for the opportunity to erase that which distances me from those that would hurt me. Eleanor Roosevelt: "Nobody can make you feel inferior without your consent."

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An anesthesiologist laments to me today about how anesthesia has gotten a lot safer - it's just not as exciting. Another anesthesiologist describes his job: "You have total control. It's just you and the patient. It's just like a video game [and] you're trying to get the highest score."

Today in the OR: "People say there's no patient contact in anesthesia. Bullshit." The anesthesiologist drives home the point by banging his hand on the patient's chest. "How you doing Cuong?" The patient jumps. He is only sedated, towel over his face, fists clenched while they cut and sew a tube into his jugular. "We're having fun; hope you are."

I have yet to see a person go under anesthesia with a smiling face above them.

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A surgeon bragging about his department wins the quote du jour: "People get mitral prolapse, aortic stenosis, big tumors in their heart. It's cool; great fun."

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The resident sees evidence of blood filling the child's chest on the x-ray. "Hemothorax, awesome!"

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I got my evaluation back from pediatrics. I was "distracting." Too "flamboyant."

One of the top three concerns of a surveyed medical school class: Loss of Self, 24%.[57] See Appendix 23.

The flamboyance is gone now though, and my smile is dimming.

The Blood-dimmed tide is loosed, and everywhere
The ceremony of innocence is drowned.
- William Butler Yeats

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You can feel the stress among the residents in the locker room. You can hear them try to pee.

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My great (in so many ways) uncle died yesterday. I hope he wasn't in a hospital. I told my mom I loved her.

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A flock of tired-faced white coats swarm in and flip on the harsh fluorescence. One minute per patient morning rounds filled with empty very-nice-to-meet-you's. I lag behind to apologize.

I was sickening; but you at once attended me, Symmachus, with a train of a hundred apprentices. A hundred hands frosted by the North wind have pawed me; I had no fever before; now I have - Martial

From Residents: The Perils and Promise of Educating Young Doctors: "Every morning a small drove of doctors gathers around the patient's bed and begins the ritual. The whole ceremony is terrifying and incomprehensible to the patient whose dignity and privacy are often needlessly compromised." One student writes, "I found the lack of everyday courtesy in such scenes disturbing and very, very common."[58]

Quoting from an article in the New Physician:

It is no accident that we doctors tend to travel in packs. I think deep down many of us are afraid to spend time alone with our patients, afraid because we know they'll begin to talk about what's really bothering them. Most patients are scared enough in one-to-one encounters. Our moving in groups of 20 virtually insures that they won't confront us with their anxieties.[59]

Quoting from the journal Academic Medicine, "Patients perceive the daily visit by the medical team to be for their benefit - an effort to collectively assess their treatment and prognosis. Many doctors, unfortunately, trained to 'treat the disease' rather than the patient, view rounds as primarily a teaching experience."[60]

I spend more time on morning rounds thinking about how I can please the senior resident (gloves ready, new dressings on hand) than smiling or even looking at the patient. From the Journal of Health and Social Behavior: "Impression management rather than learning becomes the central feature of rounds."[61]

Between white coats, a wife's hand caressing. The family's invisible too. Frankness from the Bulletin of the American College of Surgeons: "Physicians, particularly on ward rounds, actually may turn away from the patient without closing the conversation and carry on talking with the resident as if the patient were a lump of wood."[62]

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There's a big debate, I hear, amongst the MD/MPH* students. Is clean drinking water a right or privilege? Only at Tufts.

* MPH - Masters of Public Health.

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Don't the residents realize that it's not necessary to command me to go out and pick up their supper, that I'd do it if they just asked?

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I saw Chomsky speak last night. Mmm, safe sex.

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Will someone just say they don't know!

AFIB

I see residents lie to attendings all the time. Doctor to doctor. In one study, the most frequently cited reason for lying to attending physicians about something they neglected to do or check on was to "avoid looking bad" and one third said they lied because they were "deprived of sleep" or "worked an excessive number of hours."

From Medical Economics:

As a resident or student, one quickly learns that it's more acceptable to guess or ramble than to admit that you don't know the answer. And it's more acceptable to lie in order to cover up lapses in judgment than it is to admit error.... The habit of making up lab data, never admitting ignorance, and covering up mistakes may be difficult to break....[63]

One of my classmates said today, "I've learned my lesson being honest as a medical student."

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There is a solely Spanish-speaking patient on the surgical floor. None of us know Spanish, but it doesn't matter with the level of dialogue surgeons have with their patients. Case in point - a deaf woman on the service. Walking in, he lifts her gown and watches for a wince as he pushes on her belly. He gives her an everything's-OK pat. She is given a pen and the surgical consent form. She has no idea what she's signing.

Bedside manners. Appendix 24a.

I am impressed with the insight of the American Sign Language sign for doctor - two stripes across the shoulder.

ESCHEW OBSCURANTISM

Even when doctors do open their mouths, patients are spoken to in a foreign language. "We'll have to wait until the wound's granulating." "We'll put the NG to gravity." "Maybe we'll get the foley out tomorrow." Patients just nod; they seem used to it. I lag behind and translate.

Some commentators ascribe a motive for this cryptic language. See Appendix 25.

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In the first two years we spent most days in 150 person lecture halls. Some afternoons we broke up into small groups, but Tufts considers 18 students small - they just turn into mini-lectures. Quoting from a letter to the medical journal Pharos, "The poorest teaching technique currently in use is the lecture.... The only worthwhile teaching technique is a dialogue...."[64] But the first two years were at least supposed to be about teaching. And they were safe.

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Another person is described as a useless member of society. How much love have you brought to the world Mr. Surgeon? Who would miss you?

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Students at Newton-Wellesley, one of Tufts' hospitals, perform surgeries on live pigs. "It was great!" a classmate shares.

The use of animals in medical education, particularly stray dogs, remains widespread. Appendix 26.

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There was a poster In the Louisiana lab I worked in summers ago from Americans for Biomedical Progress. It had a staged-looking photo of grimacing animal rights activists protesting behind a police barrier. The caption read something like, "Thanks to animal research, they will be able to protest an average of 20 years longer." The assumption, of course, is that biomedical research was responsible for the extension of life. The assumption is wrong.

"We have not lost faith, but we have transferred it from God to the medical profession" - Shaw. See Appendix 27.

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It's my birthday and I'm on call. I lament that I want my one and only 25th birthday to go by quicker. Then I remember that every day is one and only. I will never get this day back; I will never get any day back. As Thomas Merton said, "This day will not come again." "Somebody should tell us, right at the start of our lives, that we are dying. There are only so many tomorrows" - Michael Landon.

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Wishing for the three prongs of anesthesia - painlessness, unconsciousness, and amnesia - I spend nights dreading the next day. Yesterday was like a week ago.

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Every morning a blitz of feeling sorry for myself. I grit my teeth and breathe shallow. I come home and I pace, shaking my head. I sit in the dark and touch my face.

I, a stranger and afraid
In a world I never made.
- A.E. Housman

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My best days are being bored for 14 hours. I pray to be bored. I pray to be ignored - ignorance is bliss.

The best days are only good in retrospect, because of the fear. If I knew how benign today was going to be, I would have been able to relax and enjoy the day. But you never know when you're going to be attacked.

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I can't stand the hypocrisy surrounding medical student well-being. No pilot would be forced to work the hours interns do - it's just not safe.

In fact what little progress has been made to limit hours has been at the aftermath of tragedy. See Appendix 28.

Safety aside, how about medicine as healing? Questioning every other night call*, I am looked down upon and teased as wimpy. Verbalizing my need to sleep, I was told "You're young" by a department chief. "We don't need sleep; we're residents." Ha ha.

* "Every other night call" means working 24 to 36 hour shifts every other day.

For a better sense of the masochistic machismo work ethic, see Appendix 29.

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Even now as I type, my fingers bang bang bang on the keyboard.

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Fellow traveler at Baystate surgery sums up the surgical mind in one encounter: "Don't talk to patients," the surgeon chastised him upon exiting a patient's room. "Your job is to observe." From an article called "Passing Through Third Year: A Guide for Wary Travelers": "If a surgeon says 'What are you going to specialize in, psychiatry?'... he thinks you're nuts, or he caught you actually talking to a patient."[65]

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Dostoevsky, in The Brothers Karamazov, wrote about medical specialization:

If you have something wrong with your nose, for instance, they'll send you to Paris where, they say, there is the foremost nose specialist in Europe. So you go to Paris. The specialist looks inside your nose and announces: 'Well, all right, I'll take care of your right nostril, but I really don't handle left nostrils; for that you have to go to Vienna where there's a great left-nostril specialist'[66]

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My intern: "Why don't you go eat lunch and meet me in the OR in five minutes."

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I see for myself a life as bread giver, not winner. I never want to work for money, to rent myself to anyone. "Whoever gives their labor for money sells themselves and puts themselves in the rank of slaves" - Cicero.

"Money is what we trade our life's energy for" - J. Dominguez. Appendix 30.

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A patient is coming out from anesthesia, gagging at the tube in his throat. I tell him that everything went well, that he's going to be OK. The surgeon snaps at me, "No small talk." This whole year has been doctors uncomfortable with expressions of compassion.

Dr. No-small-talk was the female surgeon - the only one on the service. But she fits right into the adolescent boy's club. The only difference in the OR is that instead of making fun of big women, she makes fun of small penises.

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I talked today to surgical residents about their lives. One woman looked at me and said, "You lose your youth." Another, "You can't be a surgeon and be a family person; my wife has been a single parent for six years"

One article in the Southern Medical Journal concludes that it's not inadequate sleep per se that's the major source of stress during the internship, but rather that the time for developing personal relationships is inadequate.[67]

Medical school can poison relationships. Appendix 31

So if surgery is such a brutal alienating career, why did they choose it? I asked.

"It's fun. It's so much power," one said. I've since asked two more residents. The first two words out of their mouths were "It's fun."

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"When you see the Golden Arches you are probably on the way to the Pearly Gates." [68]

I listen in silence to vascular surgeons talk about what great big steaks they had at their last conference. As reported in Good Medicine, "Pharmaceutical giant Boerhringer Mannheim found the perfect venue for its [1998] doctors' conference on heart attacks... Ruth's Chris Steak House...."[69]

The next day a colon cancer conference. Eight Chinese dishes. Other than the single one with veggies, no fiber in sight. At a preventive medicine presentation I arranged about the importance of educating patients about nutrition, the department provided lunch. Cold cuts, white bread, cheese, soda and potato chips.

Cabbages, not CABGs*. I ask the internist why there aren't more Ornish-like** studies. "There aren't any financial interests involved."

* Coronary Artery Bypass Grafts - open heart surgery.

** Dean Ornish has shown that heart disease can actually be reversed with lifestyle changes which include a low fat vegetarian diet.

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To sin by silence when we should protest makes cowards out of men.
- Ella Wheeler Wilcox

Most days this week I've had a choice between afternoons in outpatient surgery clinic or more time in the operating room. Not particularly fond of seeing holes in people, I surprised myself by repeatedly choosing the OR. I realize now that I could not stand to watch one more person being told they have cancer in a five minute appointment. Or watch one more person's pain laughed at. So I choose the OR where at least they're asleep.

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I live two lives - a weary one where I sleep and stare at the ceiling, and one on gravel in the day in strangle-tight collars.

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I am a reverse superhero putting on my white coat. I think about the atrocities carried out in uniform. Blaise Pascal: "If the physicians had not their cossacks and their mules, if the doctors had not their square caps and their robes four times too wide, they would never have duped the world, which cannot resist so original an appearance."

The white coat, Appendix 32.

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Finally, the button confrontation. I knew if there was one rotation where I'd get comments about QUESTION AUTHORITY it would be surgery. "You make too many statements," the chief resident said. Later, she tells me that a number of attendings wanted her to relay me a message - I was simply being unprofessional. "The patients see them," she says. Of course all the doctors sport around drug company logos, but I choke back from defending myself, from asserting myself and alas I am naked and buttonless.

The next day as I step out of the car in coat and tie I realize I am tamed. "This free will business is a bit terrifying anyway. It's almost pleasanter to obey, and make the most of it" - Ugo Betti.

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HOSPITAL PRIVILEGES

Doctor as patient on the floor. She is treated totally different. Respectfully.

A classmate was yelled at for stepping into a room with the doctor today in clinic. He jumped, so did I. That's what we were supposed to do, follow them around (getting doors shut in our faces, not being introduced, ignored, etc.) The nurse explained why this time the rules had changed. Medical students are not to go into the room if the patient is a doctor's wife.

Researchers set out to see if such differential treatment exists. They imagined a child having to see a medical student in the emergency department as being particularly affected by the discomfort and inconvenience of additional exams, so they did just such a study of ER visits. Compared with other children, children with a physician parent were only about one fifth as likely to see a medical student. Kids with doctor parents were able to almost completely bypass the medical education system.[70] Susan compares it to an airline, first class and coach. American style medicine.

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We move to a new hospital for the second half of the clerkship. It's a private hospital, so there are no opportunities to see clinic patients at all. I walk into the chief resident's office. Full sized day-glo orange poster - NO WHINING.

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I am moving tomorrow in the middle of all this. I am already exhausted. The new apartment is beautiful (lemonbalm in the backyard garden). Like that pediatric surgeon, though - with the poster of his house - what good's a home if you're never there?

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The last tenants left behind a laminated poem on the wall in the shower: "I cleanse myself of all selfishness. Resentment. Critical emotions towards my fellow beings. Self condemnation. And ignorant misinterpretation of my life's experiences."

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How barren my life is now as exemplified by how little I need to unpack.

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I hold Susan's hand and think how accessible her veins look.

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Halloween. I see my classmate with cancer on the T*. She's still in school. I ask her why she's going to Salem to party that night when she's already so tired. "You never know where you're going to be next year," she replied. A lesson for us all.

* The "T" is slang for Boston's subway system.

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I stand under the pale yellow leaves and their fading green. Shaving cream fuzz dots the bushes. What brings me joy now?

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Head cold; drowning in snot for a five hour surgery. One cannot take for granted that we can always just breathe.

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The hypocrisy of medical education is well exemplified by the anxiety accompanying daring to call in sick. My classmate was sick and missed a day. "Were you throwing up?" The senior resident demanded. "Did you have a fever?" I so wanted him to say, "None of your fucking business." Very illustrative, however, of the I, not you, decide how you feel attitude.

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Too many walls. I want to be out in the cold air, read a novel, wear real clothes.

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Terminal cancer patient. Why isn't anyone massaging him? Why aren't I?

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I saw the sun today. Hello sky. Hello trees. I realize that this was the first time I had actually seen the outside of the new hospital - it had always been too dark. One study estimated San Diego third year medical students average 25.8 minutes of daylight a day.[71]

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A patient satisfaction survey among academic medical centers was published with Tufts' New England Medical Center falling below average in "Explanation of procedural risks" and "Respect for patient preferences." So we got a memo and a lecture. Bites from the memo:

Physicians should be sensitive to emotional issues and other concerns.

Spend a few extra seconds to gently awaken the patient.

Acknowledge the patient [during morning rounds]....

Direct patient contact such as a pat on the shoulder... can mean a lot.

The lecture was even better. The doctors laughed when the respecting patient preferences item came up. "This will make it sound like you care about them," he said.

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"My" patient tells me I'm a sweet guy. Is it because I sat down? I'm embarrassed; I did nothing for him - ashamed in fact of how I've treated him. I don't even want him to notice me.

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Pointing me out, a patient's mother told the team, "He's nice; he smiles." That's the level of standards.

The same relativity infects medical students. "Everything's relative, after all," one student writes in "Med School Blues: Year Three." "My standards have taken such a dive that the absence of cruel and malicious behavior is my idea of bliss."[72]

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"We need to change the medicine; she's on free care," I am told by the head of surgery. Same day, different patient: "We have to be prudent, he has no money." From the New England Journal of Medicine: "Daily, students witness different treatments of patients with the same health needs, depending on what the dollar dictates rather than what medicine dictates."[73]

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The latest issue of Medical Economics (9/22/97) jumps out at me in the hospital library. The cover story is entitled "Getting Peanuts" picturing a doctor frowning upon his compensation. Flipping through issues I find articles entitled "Patients Who Make You Want to Flee," "Never Bad-Mouth a Colleague to a Patient," "Handling Patients You Wish You Didn't Have," and "The Key to an Efficient Office: Friendliness."

FRIES WITH THAT?

One article in Medical Economics quotes a Harvard business professor: "Doctors and other providers of healthcare can get the job done by taking to heart the lessons learned by America's most successful service companies - Federal Express, McDonald's, Wal-Mart and others."[74]

From a similar vein, HMO exec quoted in the Wall Street Journal: "We see people as numbers, not patients. It's easier to make a decision. Just like Ford, we're a mass production assembly line and there is no room for the human equation in the bottom line. Profits are king."[75] Or as another HMO chief put it, "It doesn't count unless you can count it."[76]

Richard Scott* quote: "Do we have an obligation to provide healthcare to everybody? Where do we draw the line? Is any fast-food restaurant obligated to feed everyone who shows up?"[77]

* Richard Scott is the co-founder, chairman, CEO and president of the Columbia/HCA Healthcare Corporation.

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At night I pretend as I lie down that I haven't really woken up. I imagine that it's right before the alarm went off that morning and I'm sleeping in. The day just didn't happen. I want the time between the turn of my house key to the right and the turn to the left to be lost.

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The head of the department gives a lecture on trauma. "Sure a death is sad, but it's not as expensive." I offer a rude glance. He replies, "I realize we are measuring cost in different ways."

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I express sorrow that a woman is going to be dead in six months. "Yes, but no one forced her to keep smoking," the resident responds. "I'm not a good person to give you a talk about COPD [disease caused frequently by long-term smoking]," she tells us later, "I don't have any sympathy for them."

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I got my first special personality at the new hospital today. Surgeon and corporal in the reserve, he spent the case lecturing how lucky I was to live in a country with an army as strong as ours. Do I think Hussein would have stopped at Kuwait? He responds to my incorrect answers with a game show buzzer sound.

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I have the honor to sit at the residents' table at lunch - at least here they eat lunch. They are discussing how with the new tax code you get your first $500,000 in capital gains tax-free.

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It was morning and I had just found the nurse handling my patient. I caught the doctor telling her that something was down five points; she looked concerned. I asked what had happened. It was one of the doctor's stocks that morning.

From the journal Pediatrics, "The talk in the surgeons' dressing room more often concerns the Dow-Jones averages and the golf course than it does patients...."[78]

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An exasperated physician assistant exclaims, "The patient is manipulating her whole care."

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Medical students are rats for treats, craving the simplest nod of approval from doctors for their self-esteem. You are more than a medical student, Sue tells them. They don't seem to understand what she means.

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The surgeons, between breast jokes in the OR today, tell of a Brigham cardiologist that stands behind women, puts his hands under their breasts and tells the women to jump up and down.

BREAST INTENTIONS

Described in a British expose, TUBES - an acronym courtesy of a group of medical students for Totally Unnecessary Breast ExaminationS.

A student is quoted in the article saying:

A 19-year-old woman was admitted to hospital... to investigate possible causes of a series of urinary tract infections. I immediately noticed she was very attractive.... I ran through a list of differential diagnoses trying to find one that would require me to examine her ample breasts that were being shoved towards me....[79]

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I almost felt human today. She is 93 and lying in diarrhea, so the residents put on gloves before poking and prodding. She keeps crying, "Help me." "Help me." The senior resident puts on his smile and says, "Very well then" and leaves with the others.

I went back later. Got her cleaned up. She wanted something to drink. I sat on the floor next to her bed and fed her through a straw. It took eight weeks of surgery to make a connection with another person in the hospital. She tells me the doctors laugh at her and lie to her. "I'm dying," she keeps whispering to me. "They treat me like an animal." I get her more juice, apple this time.

I don't look at her chart; I want to know her as a person. If she wants to share she will. As I leave she pulls on my hand. "I have to go," I explain to her. "I'll be back." She keeps pulling - I start to get annoyed. She was pulling my hand to her mouth for a kiss.

Hospitals have been described as human rights wastelands. From an old Civil Liberties Review article:

It is predictable that each of us will be a hospital patient on average of seven times during our lives.... The experience tends to intimidate and disorient the patient and discourages any assertion of individual rights.... Second, most patients in hospitals are simply too sick to assert their personal rights....

[The first] recorded hospital patient's rights measure... was instituted... by the National Convention of the French Revolution. It decreed that there should only be one patient in a bed (as opposed to the usual 2 to 8) and that beds should be at least three feet apart. A cynic would argue that we haven't come very far since 1793.[80]

From The Healer's Power:

To most visitors the very architecture of a hospital seems designed to remind them at every turn that they do not belong there, that they cannot possibly find their way around without assistance, and therefore that the staff must be some superior species of being.... The average person entering these precincts cannot be blamed for mentally updating Dante and reading 'Abandon all power, ye who enter here.' Over the doorway."[81]

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A patient asks that I not come into the operating room. "I would rather not be on display," he tells me. I explain that to the head surgeon. He's annoyed. He tells me to come in after the patient's draped; "He'll be so sedated he won't know the difference."

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Another senior resident smile and, "All right you take care" on morning rounds followed outside the room with a grimace and, "Did you see those teeth?"

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I felt the sun today walking between buildings to the breast clinic - the first in the nation founded by Susan Love in 1988. I can tell by the sizes of diamonds that it's a private facility. The doctor I spent the morning with was Dr. Love's last fellow. She complains about patients who get their six weeks of daily radiation closer to home rather than drive three hours to her clinic.

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A patient remarked she had never seen so many backs (commenting on how little time doctors spent in her room). I watch doctors' smiles dissolve as they turn away. "Do not turn your back on anyone. You may be painted on one side only" - Stanislaw Lec.

Vernon Howard:

The basic immorality is refusal of truth, to insist upon living from the false self. All human immorality springs from this. Most people connect immorality with observable faults, or with sex. But the terrible immoralities are the cunning ones hiding behind masks of morality, such as exploiting people while pretending to help them.

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More quotes from the front lines:

"If you're lucky you'll see scurvy."

"Don't worry, the drug rep is paying."

The patient has the gall to exercise her legal right not to have students involved in her care? "Just put away your ID badge."

Doctors referring to nursing staff as, "the girls."

Another woman threatened, "Do you want leather restraints?"

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Sitting at the nurse's desk I hear one doctor telling another doctor why - gasp - his children are attending public school. "Gives the kids more reality. Good mixing with the lower class."

Tremendous prejudice exists in medicine against the poor. See Appendix 33.

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"The idea of doctors complaining about money is like the idea of Saudi Arabia complaining about oil." [82]

Grand rounds about peptic ulcers. A slide shows that those with low income are at a greater risk. "Like doctors these days," the lecturer jokes.

I scan the room and all the sympathetic eyes. Does anyone else get at least a hint of irony at the cardiologist complaining bitterly about the plumber that charged $600 to fix his heater? A radiologist the same day complained to me that he has a fixed income of $140,000, with minimal benefits! An anesthesiologist echoed these sentiments, "People won't pay us the proper amount. And we care for people!" The head of the department joined in and reiterated, "Doctors are underpaid."

One of my favorite political cartoons depicts two executives walking down a hallway. "Sure I make $3 million a year," one says to the other. "What people don't realize is the hard work and long hours I put in." Behind them on the floor in a puddle is a woman scrubbing the floor. "Gosh," she says, "I only work three jobs on my hands and knees for $11,295 a year. He must work really really hard."

The closest I'll ever come to the denial of emotion that "no whining" embodies is the re-experiencing of classmates concerned about their financial futures. "I'll never pay back my loans," one says. The room of medical students echoes in agonized groans. The average physician nets (after professional expenses and income taxes) $160,450.[83] Even those working 30-39 hours per week averaged $117,000.[84] I wonder how far back their debts will push their BMWs.

The rationalizations start. "But what about [having to pay exorbitant amounts for] malpractice insurance?" A classmate complains. They all nod. According to Consumer Reports, doctors' malpractice premiums on average consumed less than 4 percent of their practice receipts.[85]

"Yes," responding to my cries of sheer obscenity, "but in some areas it's [salaries are] more like $70,000." "And you want obscene, there are some union garbage collectors in California that are making $18 an hour!" I am awed by their worlds, my hands in fine tremor.

For proper perspective, a review of global poverty - Appendix 34.

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Although asserting there are "an unlimited number," esteemed physician Richard Asher (first to describe such entities as Munchausen's syndrome) described the seven sins of medicine as obscurity, cruelty, bad manners, over-specialization, love of the rare, common stupidity, and sloth. He noted cruelty as, " the most important and most prevalent."[86]

I can see how doctors can participate in torture. In fact medical certification laws date back to 1766 when, "Empress Maria Theresa issued an edict requesting the court physician to certify fitness to undergo torture...."[87] Interestingly, (in Mannix's The History of Torture) torturers, "often insist on being referred to as 'doctor.'"[88]

The parallels between the education of a doctor and the education of a torturer are striking - Appendix 35.

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SAMARITANS

Tufts' medical school is in Boston's combat zone. I have a mental picture from second year of classmates eating ice cream and laughing. It was sunny out. Ten feet away, on church steps lay a man with very sad eyes. Medical students at Tufts often step over or around people on their way to class. And we're going to be doctors.

Twenty-five years ago, some researchers set up an experiment at Princeton Divinity School. They covertly watched students encounter an actor they had planted. He was shabbily dressed, slumped by the side of the road, head down, eyes closed, groaning. Less than half stopped to help.

To make the experiment more interesting, it was arranged such that some of the divinity students passing the man were on their way to give short talk on the parable of the Good Samaritan; the others were to give a talk on some nonhelping topic. It made no significant difference in the likelihood of their offering the victim help.[89]

In most countries, if a doctor happens to walk upon a medical emergency - like someone on the street having a heart attack - they are mandated, by virtue of having a medical license, to stop and help. The United States is the only Western country where a doctor can just keep on walking.

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A surgeon tells me the problem with patients these days, "Their expectations are too high."

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I realized yesterday that I remembered everything about my patient - past medical history, allergies, current medications, etc. - except her name.

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I imagine medical school as submarine, submerging for four years and only occasionally surfacing for contact with the outside world. There is no context. No time to eat, no time for oneself, no time to process. That's why all the nightmares. Surrounded, inundated by this peculiar value system, one could lose one's self.

My image of third year as basic training has shifted from images of forced push-ups to that of a cult. "Medical training works like brainwashing," Michelle Harrison wrote in A Woman in Residence. "Two major components are sleep deprivation and isolation from one's support system."[90] From an article in a journal called Culture, Medicine and Psychiatry:

The chronic sleep deprivation, the unconditional demands made by the hospital upon the intern's time, the novelty of the experiences, all isolate the intern from former social bonds and intellectual interests, and disorient him psychologically and ethically from his former self and from the lay culture at large.[91]

Delving into the cultic studies literature also gave me a distinct sensation of deja vu - Appendix 36.

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There was a scene in the doctor's lounge today. Most gallbladder operations are done laparoscopically, with small incisions, less risk, faster recovery. One patient had the misfortune of going to a surgeon who didn't even mention it as an option. Luckily, her sister is a nurse and sets her straight. When the resident tells the surgeon her new preference, he is purple-faced furious and demands to know how she found out.

Today I decided to count. One day and five blatant lies told to patients in my presence alone.

See Appendix 37 for an example of one of the more routine deceptions.

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My new patient is a homeless paraplegic with huge ulcers on her butt from sitting in an inadequate wheelchair. The doctors described her to me as a "kook"; "Look at all the scars on her arms," they said. I sit down with her. In the course of sharing, she tells me where she got the scars. It seems the only subsidized housing available was predictably handicap inaccessible. She kept burning her arms on the edge of the frying pan overhead.

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I warm up my car in the morning, but don't think to at night as I leave the hospital. I realize today, though, that my car sits longer there than on my street.

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We are told in our midterm review that this is surgery, we must be "more aggressive." As the head of the department said, "We like tough guys."

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I spent the day as patient, getting baseline blood work done to monitor the affects of AZT on my marrow. I got a needle stick yesterday; I shouldn't even have been suturing. I look down at the little green and white (pig gelatin) capsules and realize how lucky I am compared to the others who face them every day.

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Studying in the library I hear some of the new class laughing. I remember laughing in medical school.

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My minimalist criteria for new residents requires them to be adequately uncomfortable giving orders. This one fails the bill. She continues the utterly patronizing attitude of gather-around-children. In a sing-songy voice, "Students. Students." At the end of the day she points us each out. "You can go, you can go, you can go, and you can go."

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All the electricity went out today. No street lights, no traffic lights! It's a ghost town driving home. Main Street is dark - no lights on in Store 24. Candles in windows instead of TVs. Quiet.

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Quote of the week: "I'm a fuckin' cardiothoracic surgeon; you get me scrubs that fit!"

"Some of these surgeons took a bit of getting used to," one doctor writes, "much of the time they behave like petulant children...."[92]

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The chief of surgery made sure to describe Elle McPherson as a, "Nice piece of ass" today in conference.

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Junior resident: "I don't care about her; she's not my patient. It's not like I go around handing money to poor people."

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This last week I've lost the enthusiastic sparkle that defined my public persona. I am more depressed than I've ever been in my life; I've been crowded back into a corner of my mind. I've never felt so fragile. The leaves have become dry and brown and brittle.

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BEHIND THE MASK

I got The Talk again. It was right after the junior resident finished putting a central line* into a woman. I held her hand as he stuck things into her neck, her face covered with towels. She squeezed so hard.

* A central line is a large bore catheter placed in one of the major veins of the neck or chest - in this case the jugular.

A similar scene is described in the literature: "After a deftly conducted struggle in which the woman's resistance was treated as an annoyance and her cries were ignored, the central line was placed and the residents congratulated one another...." From the patient's perspective: "They covered my face because they were ashamed of what they were doing."

The author notes, "These doctors were so intent on doing things to patients, that they seemed to have little time or desire to do anything for them - such as simply comforting them."[93] "The laying on of hands was reduced to the carrying out of procedures," another doctor writes, "and words exchanged with the patient were basically viewed as tools to make those procedures go more smoothly."[94]

After the line placement, my resident took me aside. He explained that people were talking. "You come on too strong," he said. "You have to know your place." "You can't go around apologizing to patients. When you're an attending, maybe. If you want to go and talk to them then you should do it privately."

He asked me if I knew that he had covertly talked to some particular patient for hours and had evidently established quite the rapport. No, I hadn't noticed. "That's how you have to be," he said. "He wasn't my patient. I couldn't just go into the room in front of the team and be all smiley and say 'Hi.' And this woman was not your patient!" Angrily, fist clenched, he growled, "When I saw you holding her hand I just wanted to slug you."

I also got lectured on how I need to vary my bedside manner. My "sickly-sweet" style is OK for some patients, but I need to tailor it for each one. Ideally, I am told, I should have a unique way to speak to every patient - otherwise their needs may not be met. It never occurs to him that I may just have been being myself.

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I hate this I hate this I hate this I hate this. There will come a time when I live again.

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One of these days, I told myself this morning as the alarm crooned on. One of these days, I will be so in love with what I do I will leap out of bed like I did as a kid on my birthday. And if I don't sleep it will be out of anticipation, not fear. I will live for no one else. Soon - years, but soon - I will give myself permission. I will excuse myself from anger and powerlessness. "Give me a handful of future to rub against my lips" - Margaret Randall.

One Day I will...
Teach
Speak
Exercise
Meditate
Eat breakfast
Write everyday
Return to guitar
Ride a bike again
Sit on a warm rock
Wear pajamas all day
Spend days in libraries
Live every day differently
Get to know my mom better
Treat Susan as she deserves
Be so true to myself I'll be in prison
Be at peace after a Chomsky lecture
Act so as to not be ashamed at death

One Day I will...
Offer power such that no one
ever
tells me
where to be
when
what to do.

One day my days will fly, not fly by.

One Day...
I want to live
every minute, hour, day
the way
I want to live
every minute, hour, day.*

* "Tomorrow I will live, the fool does say: today itself's too late; the wise lived yesterday" - Martial.

Surgery is done. The nightmare is over. I'm free; I can do anything I want right now. Right now. I was asked what I'm going to do over break. Enjoy life, I said. But no, I'm just going to live it.

I lock myself in my room and surround myself with music. Eyes closed, I rock back and forth. Slowly my fists relax. "I get knocked down, but I get up again; you just can't keep me down."

 


 

[31] Fugh-Berman, A. "Tales Out of Medical School." Nation 20 January 1992.

[32] Fugh-Berman, A. "Training Doctors to Care for Women." Technology Review 97(1994):34.

[33] Hervada, AR. Letter. Journal of the American Medical Association 264(1990):1660.

[34] Herrick, CR. "Cognitive Dissonance and Physician Training." The Pharos 1986(Fall):2-6.

[35] Panush, RS. Upon Finding a Nazi Anatomy Atlas." The Pharos 1996(Fall):18-22.

[36] Dass, R and M Bush. Compassion in Action New York: Bell Tower, 1992:215.

[37] "The Wound is Mortal." The Clearing House 1945(February).

[38] Conrad, P and R Kern. The Sociology of Health and Illness New York, St. Martin's Press, 1990:325.

[39] Light, DW. "Toward A New Sociology of Medical Education." Journal of Health and Social Behavior 29(1988):307-322.

[40] Najman, JM and L Arnold. "An Initial Explanatory Model of Medical Students' Preferences for Patient Types." Medical Education 18(1984):249-254.

[41] Reiser, DE. "Struggling to Stay Human in Medicine." New Physician 1973(May):295-299.

[42] Feudtner, C, et al. "Do Clinical Clerks Suffer Ethical Erosion?" Academic Medicine 69(1994):670-679.

[43] Satterwhite, WM, RC Satterwhite and CE Enarson. "Medical Students' Perceptions of Unethical Conduct at One Medical School." Academic Medicine 73(1998):529-531.

[44] Groopman, LC. "Medical Internship as Moral Education." Culture, Medicine and Psychiatry 11(1987):207-227.

[45] Cassel, CK. "Musings on Disillusionment."New Physician 1986(May-June):13.

[46] Mizrahi, T. Getting Rid of Patients: Contradictions in the Socialization of Physicians Piscataway: Rutgers University Press, 1986.

[47] Journal of the American Medical Association 263(1990):533.

[48] Fugh-Berman, A. "Singin' the Med School Blues." Off Our Backs 15(1985):10.

[49] Reiser, DE. "Struggling to Stay Human in Medicine." New Physician 1973(May):295-299.

[50] Ibid.

[51] Forrow, L and VW Sidel. "Medicine and Nuclear War." Journal of the American Medical Association 280(1998):456-460.

[52] Beaudoin, C, et al. "Clinical Teachers as Humanistic Caregivers and Educators." Canadian Medical Association Journal 159(1998):765-769.

[53] McFadyen, A. "Children Have Feelings Too." British Medical Journal 316(1998):1616.

[54] Coulehan, JL. "Tenderness and Steadiness." Literature and Medicine 14(1995)222-236.

[55] Richman, JA, et al. "Mental Health Consequences and Correlates of Reported Medical Student Abuse." Journal of the American Medical Association 267(1992):692-694.

[56] Segal, D. "Playing Doctor, Seriously." International Journal of Health Services 14(1984):379-395.

[57] Keniston, K. "The Medical Student." Yale Journal of Biology and Medicine 39(1966):346-358.

[58] Duncan, DE. Residents: The Perils and Promise of Educating Young Doctors. New York, NY: Scribner, 1996:174.

[59] Reiser, DE. "Struggling to Stay Human in Medicine." New Physician 1973(May):295-299.

[60] Silverman, DR. "Narrowing the Gap between the Rhetoric and the Reality of Medical Ethics." Academic Medicine 71(1996):227-235.

[61] Conrad, P. "Learning to Doctor." Journal of Health and Social Behavior 29(1988):323-332.

[62] Sandrick, K. Bulletin of the American College of Surgeons 83(1998):13-17.

[63] Fugh-Berman, A. "Let's Stop Terrorizing Doctors-in-Training." Medical Economics 69(1992):27.

[64] Fetter, BF. Letter. The Pharos 1984(Winter):47.

[65] Ricks, AE. "Passing Through Third Year." New Physician 31(1982):16-19.

[66] Herrick, CR. "Cognitive Dissonance and Physician Training." The Pharos 1986(Fall):2-6.

[67] Ford, CV and DK Wentz. "Internship." Southern Medical Journal 79(1986):595-599.

[68] Physician's comment. National Public Radio, 11/11/95.

[69] "Heart Attacks 'R Us." Good Medicine 7(1998):22.

[70] Diekema, DS, P Cummings and L Quan. "Physician's Children are Treated Differently in the Emergency Department." American Journal of Emergency Medicine 14(1996):6-9.

[71] Barton, BP and DF Kripke. "Not Enough Light for Medical Students?" Academic Medicine 70(1995):86.

[72] Fugh-Berman, A. "Med School Blues: Year Three." Off Our Backs 17(1987):15.

[73] Eichna, LW. "Medical-School Education, 1975-1979." New England Journal of Medicine 303(1980):727-734.

[74] Medical Economics 22 September 1997:96.

[75] Wall Street Journal 18 June 1997.

[76] Himmelstein, DU and S Woolhandler. "An American View." The Lancet 352(1998):55-56.

[77] Ginsburg, C. "The Patient as Profit Center." The Nation 18 November 1996.

[78] Werner, ER and BM Korsch. "The Vulnerability of the Medical Student." Pediatrics 57(1976):321-238.

[79] Hammond, P. "Health: A Sore throat? Then Kindly Remove Your Blouse and Bra, Please." The Independent 9 December1997:13.

[80] "The Hospital: A Human Rights Wasteland" Civil Liberties Review 1974(Fall):8.

[81] Brody, H. The Healer's Power Danbury: Yale University, 1992.

[82] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, 1988:133.

[83] "How the 16 Largest Specialties Rank." Medical Economics 7 September 1998:168.

[84] "Income Rises in Busier Practices and With Time Invested" Medical Economics 7 September 1998:181.

[85] "The 'Crisis' that Isn't." Consumer Reports 57(1992):443.

[86] Rowat, BMT. "Richard Asher and the Seven Sins of Medicine. New Physciain:67-71.

[87] Illich, I. Medical Nemesis New York: Pantheon Books, 1976:77.

[88] "Doctors, Torture and Abuse of the Doctor-Patient Relationship." Canadian Medical Association Journal 116(1977):708-710.

[89] Darley, JM and CD Batson. "'From Jerusalem to Jericho.'" Journal of Personality and Social Psychology 27(1973):100-108.

[90] Harrison, M. A Woman in Residence New York: Random House, 1982:234.

[91] Groopman, LC. "Medical Internship as Moral Education." Culture, Medicine and Psychiatry 11(1987)207-227.

[92] Gordon, LE. "Mental Health of Medical Students." The Pharos 1996(Spring):2-10.

[93] Mizrahi, T. "Coping with Patients." Social Problems 32(1984):156-165.

[94] Konner, M. "Basic Clinical Skills: The First Encounters."

 


 

Reader's Comments

I actually enjoyed my surgery rotation enough that i considered a career in surgery. When I finished my first three weeks, and could go home for thanksgiving break, I started crying. I was so happy.

-- miriam Anixter, February 5, 2000
I think the reason I can't see more comments on this page with the article is that the information is so pungent and so profoundly sad. Beautifully done. I sent it to my husband who is currently in Australia. Always interested in thinking material like this. I was looking for information on micromastia for a friend's daughter and didn't expect to find this, but read it all. Am writing a second book on hormones with a critique about doctors, so it was helpful with that. Makes you want to avoid the human race, not that I'm any better. I also found and read Michelle Harrison's book that you mentioned, in New Zealand. Read it twice. Thanks Michael.

Gillian Ford, author of Listening to Your Hormones

-- Gillian Ford, January 2, 2001

I was slightly tempted (I was really more interested in doing chemistry\molecular biology\organic novel routes of synthsis chemistry\particle physics) to apply for med school before reading this article... no way..., I think I'll stick with makeing huge amounts of money working for a pharmacutical giant playing with chemicals and computer modeling...

-- Sophia Marsden, September 14, 2003
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