From: Choosing a Specialty: A Letter to a Medical Student

Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don’t expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.

Nassir Ghaemi, MD, MPH

Medical School, Part 2: The William O. Lombard Memorial Lecture on Flatus

As mentioned in Part 1, the medical school I attended was of the classic, old-school mode.  Like all the great medical schools before it, the “University Of” medical school required their students to spend the first two years of education reading approximately two million textbook pages and attending lectures and labs for over eight hours a day.  Our only clinical, real medicine experience during this time was in the personal discovery of hemorrhoids.  Classic.Minolta DSC

It was tough.  It was effective.  It was boring.  As one would expect of such a prestigious school, the students were smart and hard working.  Having succeeded in undergrad, a large number of the students found they could replicate their approach to their bachelors degree by skipping all the lectures and just reading like a madman, then acing the exam.  As a consequence, attendance was sparse.

The one year course on physiology was no exception.  The lecturer for this course was an elderly, white haired, world famous professor of physiology named Horace W. Rockport, III, or something like that.  He was the author of the most prestigious textbook of physiology at the time, a nine volume tome that was used in nearly every university.  He was a curmudgeon, to put it nicely.  Rockport would stride around the stage in front of the large lecture hall, emphasizing his points by banging his cane against the lectern or the whiteboard behind him.  Visual aids were not employed.  The idea was to sit and take in the grand wizard’s fountain of wisdom.

Rockport was not a shy man.  He lectured with great volume and authority, not only on physiology.  The great one would often include his pronouncements on politics, or society, or the world at large.  He began his lecture on lung physiology with the statement that, “Fully ninety percent of the world’s population performs no notable function other than the conversion of valuable oxygen to carbon dioxide.  That includes you people here, by the way.”  Great guy.

As the year went on, students began to realize that the lectures–besides being misogynistic, racist, and a bit loony–contributed nothing to their education that couldn’t be gleaned from the required reading of the great man’s textbook.  The audience grew more sparse.  This bothered Rockport not one bit, as he often pointed out that he was paid to talk, and he got paid the same no matter how many people were listening.  It became more hazardous to be in the audience, however.  The smaller numbers made for a more intimate experience despite the large auditorium, prompting Rockport to engage students directly, pointing his cane at somebody in the audience and questioning them vigorously.  This was okay when the questions concerned physiology, as we were prepared for that.  We weren’t prepared to answer questions about our parent’s possible infidelity leading to our conception, however.  Or why we thought ourselves smart enough to cure illnesses that God Himself had deemed appropriate to inflict on individual’s who, by this definition, deserved to suffer.  Tough questions.  The audience grew sparser still.

By the end of the academic year, there were about twenty of us left attending the lectures on a consistent basis, out of a class of just over one hundred.  This included the large German Shepard who attended every lecture accompanied his house mates from the medical student commune.  These students had to attend because they had drawn the responsibility of taking lecture notes for the class (at a cost of $100 to each student–I believe these guys went on to become entrepreneurs of narcotic prescription mills in various states).  And me, of course.  I was one of those guys that felt that I had to attend because on my schedule it said “Physiology Lecture 10:00-11:30,” so that’s where I was, usually trying to look inconspicuous somewhere in the middle rows.  I couldn’t sit in the back because the German Shepard did not like me one bit.

Rockport announced the topic of the final lecture with great solemnity, even going to the trouble of writing the title on the white board: “William O. Lombard Memorial Lecture on Flatus.”  He began his lecture with a lengthy and touching tribute to Lombard, a fellow physiologist who had evidently devoted his entire professional career to researching every aspect of the physiology of gastrointestinal vapors.  For some reason which I still do not understand to this day over forty years later, I thought the great wizard was making a joke.  I don’t know why I thought this, as the man had never displayed the slightest sign of a sense of humor during the entirety of the preceding academic year.  “What a sap,” I chuckled appreciatively from the middle rows.  I guess I thought that Rockport meant to contrast the greatness of his own career with that of lesser, mortal physiologists.  I was wrong.  Turns out that Lombard was his friend, or father-in-law, or something.  Never found out exactly what the connection was, but the “sap” comment was noted.

Rockport stopped dead in his tracks.  “Who said that?” he demanded, scanning the large lecture hall.  “It was Geller,” the owners of the German Shepard said.  “Right there, in the middle row.”  Evidently, they felt the same way as the dog.  Rockport rounded on me, jabbing violently from the stage with his cane.  “You think this topic funny, Mister Geller?” he demanded.  Yes, I didn’t say, I find this topic rather ridiculous.  But I just sat and tried not to nod.  “You think the scientific investigation into the nature and physiology of intestinal gases is unimportant?  Not worth your time or study?  Is that what you think, Mister Geller?”  By this time Rockport had come to stand just in front of me, standing at the very edge of the stage and stabbing out with his cane, trying to hit me.  I was, I thought, a safe distance away.  Unless he decided to throw the cane.  Or jump from the stage to attack me.  He had turned bright red and looked like either was a distinct possibility.

“Let me tell you, Mister Geller,” he continued.  “Let me tell you what kind of doctor you’re going to be, unless I can help it.  You, sir, are going to be the kind of doctor that thinks you know enough to get by.  That you don’t need to master the details, do you, Mister Geller?  You’re going to be a gastroenterologist, I think.  Yes, Mr. Geller, a gastroenterologist.  A doctor that makes oodles and oodles of money shoving rubber hoses up the arse of your patients, all day, dozens of times a day, every day.  Getting paid lots and lots of money to shove colonoscopes up the rear end of society’s elite, every day.  And one day, Mr. Geller, one day you’ll be looking up some poor patient’s arse with your fancy colonoscope and you’ll see something!  Do you know what you’ll see, Mr. Geller?”  I had to shake my head at this point, as it was clear he wasn’t going to move on until I did.  “You are going to see a nice fat, juicy polyp, that’s what you’re going to see.  A nice fat, juicy colonic polyp, Mr. Geller.  And I know you’ll want to take out that juicy polyp, Mr. Geller, because you can charge a lot of money to take out the colonic polyps of our society’s elite colons.  So you’ll position your colonoscope, and you’ll ensnare the nice, juicy polyp with your electric cautery snare, Mr. Geller, and you’ll tell your pretty young assistant to turn on the current to your electric snare.  And do you know what will happen then, Mr. Geller?  Do you know?”  I had to admit that I did not know.

“No, Mr. Geller, you will not know.  You will not know that flatus contains 2% methane gas, a highly inflammable compound.  You will not know this simple physiological fact, Mr. Geller, because you think it unimportant.  Laughable, even.  You will not appreciate the significance of the fact that the gas within your patient’s colon is highly inflammable.  You will not.  And because you are an idiot, Mr. Geller, do you know what will happen?”  I think I might have been smiling at this point as I admitted that I really did not know.  “Your patient, Mr. Geller, will EXPLODE!  Yes!” he said gleefully, “Your high society, polyp possessing patient will explode in your face!  Pieces of your patient will spray across the endoscopy suite, bits of flesh will spatter the walls.  And then do you know what will happen, Mr. Geller?”  I shook my head.  The dog may have barked at this point, I wouldn’t be surprised.  “Then, Mr. Geller, the poor patient’s widow will sue you for medical malpractice.  And then a jury will pronounce you guilty of being a stupid, ignorant git.  And then your malpractice insurance company will cancel your policy.  You’ll be out of a job, Mr. Geller.  Out on the street, destitute!  That’s what going to happen to you, Mr. Geller, because you don’t respect science!”

“If that does happen, Professor Rockport,” I said, “I’ll still be sucking your precious oxygen.  And I’m pretty sure you won’t be.”

Medical School, Part One: Feeling Bad for the Patient

Long ago I attended medical school in the midwest.  It was a public “University Of” school that enjoyed an excellent reputation, especially amongst the members of the school itself.  At the time (this was the early part of the last century), they claimed to be “the number six medical school in the country.”  I have no idea how they came up with this fact.  Suffice to say, they have spent every moment of the last one hundred years striving to overtake every institution above them on that imaginary list.IMG_1139

There was a unique dynamic in my midwestern state when it came to medical education.  In addition to “The University Of,” there was also a long established medical school in the city, as well as a brand new upstart medical school at the State University.  The State University already had a well respected veterinary school and one of the best osteopathic medical schools in the nation.  This fact led the brilliant State University administrators, faced with the task of naming the newly accredited allopathic medical school in a hip and distinctive way, to call it “The School of Human Medicine.”  I’m not sure what organisms the administrators thought their graduates from the osteopathic school were treating up to that point, by I’m assuming something distinct from animals or people–aliens, I guess.

This triumvirate of medical schools led to a great deal of competition on multiple levels:  for patients to care for in order to train their students, for prestigious residencies once their students graduated, and faculty.  It was a constant war, with faculty members being stolen back and forth amongst the three schools.  In response to this competition, each school developed its own unique personality.  “The University Of” simply made sure that everyone knew that they were the best and the most prestigious.  For a while they would spout the tag line “The Harvard of the Midwest,” until one marketing savant realized they could do better.  They then claimed that Harvard was just “The University Of” of the East.  You get the idea.  The urban medical school prided itself on its gritty reputation of training “real doctors,” emphasizing their large caseload inherent in a predominantly indigent population.  The State University emphasized their new, modern teaching approach. The curriculum incorporated an emphasis on compassionate care and alternate, New Age type approaches. The teaching method was also new and different.  Instead of the classic lecture for two years followed by two years of closely supervised clinical experience epitomized by the “University Of” format (and Harvard, of course), they developed a computer based, “teach yourself to be a doctor” curriculum.  It was very ahead of its time.  It was also a disaster.  The graduates of this system could always be identified by their inability to  pronounce any medical term over two syllables correctly, since they only interacted with a computer screen for two years.  They were cruelly mocked when they finally hit the wards.

This dynamic was exemplified in a joke popular in the state at the time.  A recent graduate from each of the medical schools is asked to evaluate a patient in the emergency room.  The patient is a seventeen-year old male with a one day history of worsening right lower quadrant abdominal pain, nausea, and fever.  Physical exam demonstrates exquisite tenderness over the appendix.  The first student, a recent graduate of “The University Of,” says, “I’m quite familiar with this type of patient.  I have read over a dozen journal articles on just this problem and given a Grand Rounds lecture on this exact condition.  This patient has acute appendicitis and needs an emergency appendectomy.”  “And how would you do that operation?” the “U of” graduate is asked by the professor.  He shrugs.  “No clue,” he says, “we don’t actually go to the OR.  That’s just technician stuff.”  The second student, from the urban training program, snorts derisively.  “The dude’s got a bad problem in his gut.  I’ve never read anything in a book about this, but I’ve taken care of twenty of these.  I need to get him to the operating room.”  “What’s your preoperative diagnosis?” the professor asks.  The urban graduate shrugs.  “Who knows?  Doesn’t matter.  Never let the skin of the patient stand between you and your diagnosis, that’s what we always say.”  Finally, the “State University” graduate is asked his opinion.  He looks distinctly uncomfortable when asked for his diagnosis.  Finally, he answers, “To be honest, I’ve never read anything about a patient like this.  As a matter of fact, I’ve never even encountered a patient with this problem during my education.  However, I do feel really, really bad for him. And I hope he gets better soon.”