Smash the Two Dimensionality of Medical Training
“Who are you outside of medicine?” asks Almost No One in medical training. And that is the problem.
Medical education has a way to reduce a wholesome person to its mere two dimensions: you are either smart, or you are not; you either learn fast, or you are slow; the attendings either like you, or your rotation is a bust. And frankly, we have all been on both sides of the binary, multiple times. My Chinese ancestors put it perfectly in an idiom: 逆水行舟, 不进则退—like rowing a boat upstream, if you stop moving forward you fall back. It’s exhausting.
Classes, anatomy labs, exams, clinical rotations, global health projects, research papers, medical advocacy groups, leadership activities, residency applications, interviews…medical training casts its larger-than-life shadow over you, forcing you to shed the fullness of your personhood outside of medicine. Until one day, you are striving for nothing but becoming the smarter student, the faster learner, and the more likable trainee.
“Zed, what specialty are you going into?” Miriam, my hospital medicine attending asked me. The mockery in her tone was palpable.
From day one, I had been failing to impress Miriam as a medical student, and she had seized every opportunity to let me know what a disappointment I was. “Isn’t this something that any first-year medical student should know? Which year are you in now, Zed, third year?” Miriam said in front of our whole hospital team during rounds, the first time I failed to answer her “pimping” question right.
I had just gotten off a delayed international flight from China and broken free from my three-year-long emotionally abusive relationship prior to starting my first clinical rotation — my brain, body, and self-esteem were all in terrible shape. Even if I was in the prime of my intellectual life, I could still have answered a question wrong, just by pure chance. But I was never able to recover from my initial bad impression as a terrible medical student in Miriam’s eyes. And for reasons anyone who has ever experienced anxiety would understand, the negative reinforcements perpetuated my bad performances in front of her, over and over. I was stuck in a vicious cycle.
“Um, family medicine,” I answered.
Spoiler alert! I had very wholesome reasons for going into family medicine and went on to become a well-respected country doctor. But back in that hospital ward, naming my dream specialty felt like admitting defeat.
“Ok, yeah, that’s probably for the best. Family medicine really suits you.” Miriam answered, with a smirk on her face. She didn’t mean that I had a broad medical knowledge base, or that I was great at caring for the whole person and families, or that I made people feel heard and comfortable. What she meant was that I was simply not good enough to match into any other specialty — a common prejudice against primary care providers in medicine.
Throughout my four weeks with Miriam, I felt the layers of who I was as a person being stripped away, little by little, leaving behind a single identity: a bad medical student. It didn’t matter that I was a first-generation immigrant on a student visa, making it through an Ivy-league medical school; or that I had spoken at (in my second language) international conferences on my accomplishment in founding China’s first student-run free clinic; or that I was a good runner, daughter, friend, or person. At this very moment, and many different versions of the same moment thereafter, I was reduced, compressed, and trimmed down in order to fit into the two-dimensionality of medical training: good at medicine, or bad at medicine. No mas.
A few months later, I had another hospital rotation. This time, at a different hospital, and with a different team. My new attending, Jane, thought of me as a good medical student this time. She involved me in patient care, relied on me for information, listened to my plans, and did not ridicule me — but all after she got to know me as a person. She asked me where I was from, what my interests were outside of medicine, and shared with me about herself.
“Zed, what specialty are you going into?” Jane arrived at the same inevitable question as Miriam once did. But from Jane’s tone of voice, I knew she was genuinely curious about it, not to confirm or deny my career choices.
“Family medicine”, I said with pride.
Jane wrote a bunch of sticky notes in my pocketbook on my last day of the rotation, with capital letters that said “GIVE INTERNAL MEDICINE A CHANCE, TOO!”
I went on to complete a family medicine residency. My choice was not swayed by any attending’s strong opinions. But if I were not sure which specialty I wanted to go into, despite Jane’s rescue of my self-esteem, Miriam would have talked me out of applying for internal medicine. The truth is, everyone who makes it into medical school has what it takes to be whatever they want to be. And the world needs more physicians in all specialties. Medical education should aim to broaden the paths to these choices, not narrow them.
It was after residency training that I truly had the space to re-expand my whole person in different directions again. I started to read and write more. I ran 14 half-marathons and covered many amazing trails in the beautiful PNW. I got Moshi Moshi, my Labradoodle puppy, and we completed the therapy dog course together. At the same time, I became a faculty at a very reputable medical school and had students and residents rotate with me for months at a time.
Another spoiler alert! I was determined to NOT diminish my students.
“Dr. Zha, what are your expectations of me for this rotation?” asked Betty, a second-year medical student who was about to start a six-month rural track curriculum with me. Six months is a long time. In fact, that’s 1/8 of a person’s medical school training! I got to make a big impact on someone’s medical career. But perhaps more importantly, I had the chance to really get to know a person — a full, three-dimensional person.
“I want you to love full-scope family medicine, take care of patients in clinic and in the hospitals, catch lots of babies…” I caught myself before listing more things. “But the most important thing on this rotation is…” Betty opened her pocketbook and clicked her pen.
“I want you to not lose the sense of who you are. You were a full-fledged person much before you become a full-fledged physician. Don’t let medical training take any of that away. Don’t let me take any of that away. ” Betty looked up from her notebook, initially with a puzzled look on her face, then just smiled.
Betty and I had great fun doing all the things I listed above. At the end of her time with me, she was catching babies and doing trigger point injections on her own, with my supervision. Outside of medicine, we sampled local foods together, ran 100 miles in a month for a fundraising event (with Moshi Moshi), and we critiqued each other’s writings (turned out she was a writer, too). Getting to know Betty as a person made me a better teacher, her a better learner, and us a better care team for our patients.
I give you one guess which field of medicine Betty decided to apply to. (And yes, it was a happy ending.)
I am not saying that all attendings should be friends with their trainees or hang out outside of work. Jane and I never hung out. Betty and I hung out a lot. And Jane made a positive influence on my medical career, a favor I passed on to Betty.
The hierarchy of medicine is important to respect, most of the time. After all, it’s also the chain of liability: when something goes wrong, the main responsibility falls on the attending, then the fellow, residents, and rarely the medical students, etc. At the same time, the authoritarian, all-consuming culture of medical education needs to make a shift, in order to give space for the people who practice medicine.
Attendings, make some space for your trainees to express themselves in languages other than medical jargon. Talk to them like you would talk to people outside of medicine. Don’t shed your sense of humor when you put on that white coat. Help smash the two-dimensionality of medical training. The movement won’t start unless you take the lead.
Instead of being the rushing stream that could swallow a boat, a good education should be the soil that nurtures a tree, allowing them to grow taller and branch out in all dimensions. How else can a tree provide the best shelter for those who need it?
