28 September, 2014

Confessions of the hidden curriculum

Hidden curriculum - a term coined in the 1960s to describe the idea that education is a process of
Source: https://drkevincampbellmd.wordpress.com
socialization; currently in vogue to describe the many things medical schools teach medical students that are not officially part of the curriculum, i.e. the ways in which American medical students are socialized into becoming physicians.

Although this term, and the concern about the unintentional and often negative lessons that medical students learn on their way to becoming licensed physicians (who then maintain the status quo of American medicine), greatly precedes my medical education, I never heard it directly discussed or addressed when I was a medical student (2003-2008, minus a stint as an anthropology graduate student). And for a long time, I focused my recollections on the non-traditional educational experiences that I was lucky to have and that profoundly shaped the kind of doctor I wanted to be - an undergraduate summer spent studying how medical mistrust affects African-American women seeking prenatal care in an inner-city neighborhood; first-year encounters with hospice care and lessons in "breaking bad news" from the awesome Tammie Quest, who now directs Emory's palliative care center; and impassioned discussions of structural violence early in my training (what is now called structural competency, or a recognition inequalities in health affecting individual patients and influencing the relationship between patient and provider arise from social structures and institutions). 

I have never forgotten the day a lecturer used the term "white privilege" and a (Caucasian, socially and economically privileged) female student walked out.

That is not to say that I would claim to be unaffected by the hidden curriculum. In fact, as I sat down to write this, I wondered whether I'm writing now because my new role, teaching medical ethics and social responsibility to medical students, involves shining a bright, bright light on the hidden curriculum and reflecting deeply on these experiences...or because, as a licensed-board-certified-fellowship-graduated-attending-physician-faculty-member (pick your choices of adjective and noun), I may not be tenured but I am indubitably beyond the reach of those who inculcated me into the hidden curriculum.

On my first day of medical school, one of the deans told a fairly devastating story about a recent graduate who died (I think in a mountaineering accident) the day after his graduation. The point of the story was to remind students to make the most of each day and not postpone "life" until the end of medical school (four years later). I thought about that advice nearly every day and tried my damndest to practice it, but after all was said and done, I hated medical school. The closest I came to succeeding was when I took a leave of absence to study medical anthropology at Oxford. 

Most of the time, I felt like I was being taught by old white guys who had neglected their families for years in favor of their careers (hopefully, their patients got a little of the spoils, but I was doubtful) and who wanted to smugly tell us how they had finally learned the importance of work-life balance but secretly, bitterly hoped we'd make all the same mistakes.

That is a terrible overgeneralization - I also had many extraordinarily gifted teachers - but it was an overarching theme.

During my first semester, I was in a long-distance relationship. The leader of my "problem-based learning" small group had offered to move our required session to help me make a surprise visit to my then-boyfriend's town, several states away, over a long weekend. I filed a request to book a room for the new time slot. At the gym that evening, two days before the scheduled trip - my heart is racing remembering how stunned and livid I was - I received an e-mail from one of the associate deans saying that we were not allowed to reschedule our small groups, nor was I allowed an absence. 

I met with this dean the next day, and he had the nerve to tell me "too bad" and "I want to get home to my family on Friday afternoons too." I can't remember what I replied, although I know we came to some sort of compromise, because I went on the trip (and blessedly broke up with the guy), and I know that after I walked out, I cried. Looking back, I want to say something very rude, followed by a more articulate statement of my incredulity: He wanted to get home to his family on Friday afternoons? His family on the other side of our city? My boyfriend and all of my closest friends lived 500 miles away; my entire extended family lived at least 1000 miles away. Seeing someone - anyone - I loved on a weekend wasn't a matter of leaving work an hour early on a Friday afternoon; it required careful budgeting and plane tickets or several full nights of sleep and a grande quintuple latte. 

But there was already a lesson there - don't dare to suggest that family is more important than obedience. (a.k.a. I say "Jump!" You say, "How high?")

Playing on natural rock slides in Sacsayhuamán
Cusco, Perú, July 2004
Life went on. I got good grades and a good Step 1 (the first of the three-part general licensing exam) score. I edited the literary journal and spent the summer in Peru, made new friends and explored the local restaurant scene. I rented the first apartment that was completely mine (on the top floor of a 100-year-old building, with gorgeous crown moulding and hardwood floors, a French balcony and a wall of built-in bookshelves in the bedroom) and painted the living room a questionable mix of bright yellow and dusty violet, to complement a Federico Coscio painting I'd hauled back from Cusco. 

I started my third year and was mostly disappointed. I was expecting to find intense personal satisfaction from regular interaction with patients, as well as opportunities for interprofessional growth, collaborating with colleagues across many levels of training and disciplines, including nurses and other support staff. (I am fairly certain anyone who has attended medical school is laughing at the degree of my naïveté.) And like many people before and after me, I instead discovered that doctors spend very little time at patients' bedsides; that there is a seemingly enormous amount of "scutwork" that is unrelated to learning and frequently apparently unrelated to patient care; and that medical students earn good grades in the clinical years (traditionally, the third and fourth, with the first two spent in the classroom, though this is changing) by quickly identifying "scut" and getting it done. 

Some people got depressed. I filled out applications for graduate programs in foreign countries. Before I could flee across the ocean to figure out what my real calling in life was supposed to be, my father had an implantable cardioverter defibrillator (similar to a pacemaker) placed. It was intended to help his heart beat more effectively and also to restart his heart if it ever stopped. Several months later, he was hospitalized again after it became infected. One night, when I was on-call for the labor and delivery ward, my family called and asked me to come home. Near tears, I called the course director, the physician who was in charge of my rotation (a block of time, usually four to six weeks, but sometimes longer, devoted to studying the same specialty - e.g. obstetrics and gynecology - and seeing patients in that specialty's clinics and in the hospital). 

Some background: I was not always the perfect third-year medical student. I knew when I applied to medical school that I wanted to be a pediatric oncologist, and so I sometimes struggled to feign interest in specialties that had little relevance to my goals. (Most medical students quickly learn not to admit their true passions, but to pretend that they want to do whatever it is that the physician they are working with that day does. I am a terrible actress.) But I was a solid OB/GYN student. In college, I volunteered as a peer health educator, helping to prepare students before their first gynecologic exams and weigh birth control options, and accompanied sexual assault survivors to the ED. I really cared about women's health (and still do). I had also done well on all of my rotation-specific exams, and there was every reason to think, in this the second-to-last week of the rotation, that I would get a well-deserved A. 

So you might expect that my course director would have expressed concern, reassured me about my anticipated absence, and wished me a safe journey home. 

Not quite. 

I explained the situation as succinctly as I could, trying to accurately summarize 35 years of medical history while conveying our real fears that my father might die. After a pause long enough to qualify as awkward, she said, "Well...you need to do what you think is best." 

Once again, the incredulity with which I recall her words has blurred any recall of my real response. Eventually, I must have told her that I planned to leave the next day but would attend clinic in the morning, as my sister had been unable to find an early flight. To my continued astonishment, she told me that I was allowed to miss two days and, if I needed to be away longer, we would discuss how I would "make up" my absence when I returned. 

Yes, that is how a physician, a healer, a woman with young children (and, presumably, parents of her own), whom I previously respected and admired, responded to a dedicated young student who had just told her that her father was gravely ill. 

The next morning, my resident, a kind and gentle young man whose wife was nearly nine months pregnant, sent me home after a couple hours, shocked that I would try to see patients while wondering if I would ever see my father again.  That night, my sister and her best friend picked me up at an airport two hours away and took me straight to the hospital. And over the next few days, my dad slowly improved. His pacemaker was removed and the following weekend he was discharged home. (His infection lingered and recurred at least twice more, leading to the prolonged intensive care stay that he described here.)

I returned to school, completed the rotation and earned an A on the exam. My course director brusquely informed me that my grade would remain an "incomplete" on my transcript until I presented myself to the gynecologic oncology service for two additional days, and I explained that it would have to wait, as I was leaving as soon as I finished my required third year rotations, first for an away rotation (a rotation at another institution) in pediatric neuro-oncology (brain tumors) at St. Jude Children's Research Hospital and then for my leave of absence at Oxford University. 

This is how I like to remember Oxford - 
deep conversations over good wine.
Linacre College, October 2006
You would be wrong if you thought this demonstration of intellectual passion and commitment to scholarship fazed her at all. You would also be wrong if you thought that she'd wave her hand and send me on my way when I contacted her a year and a half later to announce my impending return from the UK. 

So one sweltering morning in August, I stumbled bleary-eyed from a friend's air mattress (my new lease hadn't started yet) in order to make my required appearance. My bag contained a jumble of references for my unfinished master's dissertation on hope and uncertainty in treatment choice for childhood cancer, as well as scribbled notes for the personal statement that would accompany my application for pediatric residency slots. 

The next two days spent holding retractors (devices that pull back flesh during surgery) and having residents and attending surgeons ask me detailed anatomic questions (the answers to which I had forgotten within seconds of finishing the Step 1 exam) were perhaps two of the most meaningless of my life. 

When I wasn't pondering the metaphysical impossibility of ever getting those 48 hours back, I begin to develop a sort of personal creed of work-life balance, further refined over the next seven years of medical education. It goes something like this:

If what I'm doing is NOT (1) directly improving the health and well-being of my patient or my community; (2) educating myself, so that I can improve the health and well-being of my patients or society; or (3) directly helping my colleagues, so that they can go home sooner, see their families, or just take a deep breath, then I should be doing something else.

A few months later, I had an elective, which I chose (emphasis on choice) to spend in the surgical intensive care unit. At one point, I was asked (mockingly) if I would like to remove a patient's Foley (urinary) catheter. ("Jump!") I responded with, "Yes, ma'am, I would love to!" ("How high?!") Afterwards, I thought, Once I graduate, I will never fake enthusiasm again. 

Life is too short, and there is too much about which I am so deeply and genuinely passionate, to pretend.
Sunrise over Mount Hood, seen from the tram to OHSU
(I was interviewing for residency and thought, I'd get up at 5 AM every day to see this)
Portland, Oregon, November 2007
I was lucky in medical school in a lot of ways. I have never had a supervisor curse at me. I did work with a surgeon who had a knack for choosing borderline-inappropriate positions in which students were expected to assist with retracting, but I never had anyone demand sexual favors for grades or privileges. I was never asked to do anything blatantly unethical, immoral or illegal. (If you have access to an academic library and are interested, I suggest reading Jim Dwyer's paper, "Primum non tacere: An ethics of speaking up.")

And I had an inoculation of sorts: I arrived at medical school profoundly influenced by my mother, a child life specialist who had been teaching me to see the whole person first, and to advocate for him or her, since I learned to talk, and affected by my father's hospitalizations. Because of them, I will always be a family member (a daughter and now a mom) first, and a doctor second, and a better doctor for it.

I want to believe that.

And most of the time, I really do. Because of that conviction, I can't dismiss my experiences as a minor. How we as educators treat our students, how we acknowledge their personhood outside the classroom, outside the clinic or hospital, matters. Doctors who are stressed, depressed, burnt-out, or bitter cannot provide good medical care...not for very long, anyway. We can't ask medical students to respect the struggles of a patient with diabetes trying to afford healthy food on minimum wage, or teach them to respect their nursing colleagues and pay attention when a nurse comes to them with a patient safety concern, if we are also teaching them that we don't respect them, their loved ones, or the fact that sometimes their loved ones need them the most - more than their patients and certainly more than their books.

To teach a future doctor to see the whole person in their patient, we have to see the whole person in our student.

This is something I still have to work to reconcile with the myth of the good doctor, who is always on call, always at the patient's bedside, a figure who is barely recognizable in modern medical practice, but still ingrained in our collective medical psyche. 

This summer, I had the opportunity to attend a workshop for young doctors who are interested in developing new treatments for cancer. On the last day, I hiked up here and stopped to remember and thank the world and all the people in it who helped me get to this point,  by being nothing like the people I've written about here.  Most especially my dad.
Vail, Colorado, August 2014

I will live so as to embody 
(i) an open-minded receptivity toward creation and creativity; 
(ii) a celebration of life and all that is good in humankind; 
and (iii) a caring hand extended toward the least of my brethren. 
- Gregory W. Schneider