but i’m sitting here, in a reflective mode, thinking about the last four years.
studying medicine has been a bit of an endurance test. i’m wondering if practicing it will be the same. i’m not expecting it all to be, but i am wary of the bureaucracy of hospital systems and the glacial speed in which change occurs in such settings. i’m sure some resilience and capacity for enduring will be necessary.
the majority of the content of medical school is not particularly intellectual - some areas are of course, but most medical schools aim to produce safe and competent interns, not exceptionally intellectually gifted doctors. and this is a good thing. the difficult part of medical school is really to do with the amount of material that has to be studied. if you can pass an undergrad degree (any degree really) and can be diligent in your studies, you can get through medical school. accepting that there’s a limitless amount of information out there, and knowing where your own limits are in terms of knowledge are both important aspects to becoming a doctor.
recently i was speaking with the partner of a first year registrar about graduating (although he was not in health, he has some perspective on studying medicine through his partner) and the mix of art and science in medicine. he was very firmly of the belief that the main approach as a doctor comes from a rigid scientific algorithmic type of model - where the absolutes of knowledge are drawn to bear on the specific patient you’re dealing with. he said this in response to my claim of the benefits of having a generalist arts degree in being able to communicate well and to be able to deal with ambiguity - and that medicine had far more shades of grey than it is thought to have.
of course, it’s vitally important to have understanding of scientific principles and concrete (or as concrete as possible) understandings of pathophysiology and the mechanism behind treatment, yet this all fails to be of much benefit if there is no engagement with the more unknown/subtler/qualitative aspects of the patient and their disease or condition. this is partly because the science is still not finished.
pharmacogenomics is a burgeoning field that will change many treatment options in the decades to come - but right now, there are drugs we use that don’t work in certain people because of their genes - or have a reduced effect. tamoxifen (used in treatment for specific types of hormone receptor positive breast cancer) is converted to endoxifen (the active substance) in the body by a particular enzyme. the gene that is responsible for this enzyme can have a single nucleotide polymorphism that reduces the metabolism of tamoxifen to endoxifen - thus limiting the efficacy of the treatment and increasing the risk of recurrence. it’s now possible to test for the gene responsible (although the evidence doesn’t suggest this is best practice) and thereby determine if that treatment is worth using or not. this has only come to light in the last few years. imagine how many other drugs may not be functioning as we expect because of yet to be discovered/understood gene interactions.
there was a study recently that examined placebo - but did so by letting the patients know that they were taking a placebo - and still found a significant benefit to using placebo (and yes, it was a small study, but this just indicated the need for more research). alongside this are studies showing the importance of the doctor patient relationship in outcomes.
and then i think of the choices people come to - being able to help a patient decide about pursuing treatment (with all the associated side-effects) or allowing the natural progression of their disease to follow through. the sorts of skills to deal with these issues are not found in didactic and rote learning or rigid algorithmic models. these require the ability to listen, to discuss, to question and to allow time to understand what people need.
i hope the next few years will see me finding a path that straddles the art and science, and allows me to develop my skills and knowledge in both areas.
a couple of days ago was our gradation. as part of the ceremony our cohort had elected to read the geneva declaration (in it’s fourth amendment from 2006) as our oath. it was surprisingly reaffirming about why i decided to head into medicine - and the experience was quite unifying for our year group, which had become more fractured over the four years (the levels of cynicism seemed to have expanded during this time as well). at least, that was how it felt to me.
i’ve observed these changes in others, and in myself, over the duration of the course. and i recall reading a study which showed that the altruism that accompanies students entering medical studies wanes over time. also, that this continues into their practice as a doctor - jaded, cynical, weary and detached are common archetypes ascribed to doctors in fictional medical novels, and anecdotally i’ve seen these attributes many times in more senior doctors.
it appears that the relentless demands of studying medicine, the hours required, the content to learn, the detail to memorise, the pressure of performing amongst a group of high achieving individuals and the awareness of the insurmountable knowledge mountain to be scaled can take away the capacity for caring, for compassion, for allowing and finding meaning in each interaction with patients. and the enculturation of medicine is so strong, it can be hard to remember your humanity - and harder still to allow it to be present and available in your practice. to survive many create boundaries and compartmentalise - which in and of itself can be incredibly useful for dealing with traumatic situations - but at the same time this disconnection from self, from lived experience can harden even the most well intentioned and altruistic person.
early in our course we discussed Osler and Aequinimitas as part of our professionalism and leadership course. i had previously been exposed to the idea of aequinimity through studying the philosophy of buddhism in my arts degree. in that particular learning i equated the term as an equivalent of ‘detached compassion’ - as providing a way to be calm in the world regardless of what was occurring. my understanding was that this state allows people to be present and compassionate, but to remain apart from the turmoil created by emotional engagement. i think Osler had a slightly different definition, sometimes interpreted as objectivity but probably closer to the idea of an inner calm - being the same sort of goal the buddhist notion hopes to achieve. for me, this doesn’t mean compartmentalising or creating boundaries though - it is more about accepting the complexity and grandness of life, which includes suffering and sickness, in order to be able to understand and offer compassion without succumbing to excessive empathy.
i had no idea i was about to write all of that - will have to read it later to see if i agree with it.
anyway, back to the oath - it gives me hope for all of us, and hopefully it gives us guidance for our future careers.
for interests sake, here’s what we spoke:
At the time of being admitted as a member of the medical profession:
I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practise my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life;
I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
I make these promises solemnly, freely and upon my honour.