Howard S. Becker and Blanche Geer

The Fate of Idealism in Medical School

Becker H.S., Blanche G. The fate of idealism in medical school// American Sociological Review, vol. 23, 1958.

Medical students enter school with what we may think of as the idealistic notion, implicit in lay culture, that the practice of medicine is a wonderful thing and that they are going to devote their lives to service to mankind. They believe that medicine is made up of a great body of well-established facts that they will be taught from the first day on and that these facts will be of immediate practical use to them as physicians; They enter school expecting to work industriously and expecting that if they work hard enough they will be able to master this body of fact and thus become good doctors.

In several ways the first year of medical school does not live up to their expectations. They are disillusioned when they find they will not be near patients at all, that the first year will be just like another year of college. In fact, some feel that it is not even as good as college because their work in certain areas is not as thorough as courses in the same fields in undergraduate school. They come to think that their courses (with the exception of anatomy) are not worth much because, in the first place, the faculty (being PhDs) know nothing about the practice of medicine, and, in the second place, the subject matter itself is irrelevant, or as the students say, 'ancient history'.

The freshmen are further disillusioned when the faculty tells them in a variety of ways that there is more to medicine than they can possibly learn. They realize it may be impossible for them to practice medicine properly. Their disillusionment becomes more profound when they discover that this statement of the faculty is literally true. Experience in trying to master the details of the anatomy of the extremities convinces them that they cannot do so in the time they have. Their expectation of hard work is not disappointed; they put in an eight-hour day of classes and laboratories, and study four or five hours a night and most of the week-end as well.

Some of the students, the brightest, continue to attempt to learn it all, but succeed only in getting more and more worried about their work. The majority decide that, since they can't learn it all, they must select from among all the facts presented to them those they will attempt to learn. There are two ways of making this selection. On the one hand, the student may decide on the basis of his own uninformed notions about the nature of medical practice that many facts are not important, since they relate to things which seldom come up in the actual practice of medicine; therefore, he reasons, it is useless to learn them. On the other hand, the student can decide that the important thing is to pass his examinations and, therefore, that the important facts are those which are likely to be asked on an examination; he uses this as a basis for selecting both facts to memorize and courses for intensive study. For example, the work in physiology is dismissed on both of these grounds, being considered neither relevant to the facts of medical life nor important in terms of the amount of time the faculty devotes to it and the number of examinations in the subject.

A student may use either or both of these bases of selection at the beginning of the year, before many tests have been given. But after a few tests have been taken, the student makes 'what the faculty wants' the chief basis of his selection of what to learn, for he now has a better idea of what this is and also has become aware that it is possible to fail examinations and that he therefore must learn the expectations of the faculty if he wishes to stay in school. The fact that one group of students, that with the highest prestige in the class, took this view early and did well on examinations was decisive in swinging the whole class around to this position. The students were equally influenced to become 'test-wise' by the fact that, although they had all been in the upper range in their colleges, the class average on the first examination was frighteningly low.

In becoming test-wise, the students begin to develop systems for discovering the faculty wishes and learning them. These systems are both methods for studying their texts and short-cuts that can be taken in laboratory work. For instance, they begin to select facts for memorization by looking over the files of old examinations maintained in each of the medical fraternity houses. They share tip-offs from the lectures and offhand remarks of the faculty as to what will be on the examinations. In anatomy, they agree not to bother to dissect out subcutaneous nerves, reasoning that it is both difficult and time-consuming and the information can be secured from books with less effort. The interaction involved in the development of such systems and short-cuts helps to create a social group of a class which had previously been only an aggregation of smaller and less organized groups.

In this medical school, the students learn in this way to distinguish between the activities of the first year and their original view that every-thing that happens to them in medical school will be important. Thus they become cynical about the value of their activities in the first year. They feel that the real thing - learning which will help them to help mankind - has been postponed, perhaps until the second year, or perhaps even farther, at which time they will be able again to act on idealistic premises. They believe that what they do in their later years in school under supervision will be about the same thing they will do, as physicians, on their own; the first year had disappointed this expectation.

There is one matter, however, about which the students are not disappointed during the first year: the so-called trauma of dealing with the cadaver. But this experience, rather than producing cynicism, reinforces the student's attachment to his idealistic view of medicine by making him feel that he is experiencing at least some of the necessary unpleasantness of the doctor's. Such difficulties, however, do not loom as large for the student as those of solving the problem of just what the faculty wants.

On this and other points, a working consensus develops in the new consolidated group about the interpretation of their experience in medical school and its norms of conduct. This consensus, which we call student culture, focuses their attention almost completely on their day-today activities in school and obscures or sidetracks their earlier idealistic preoccupations. Cynicism, griping and minor cheating become endemic, but the cynicism is specific to the educational situation, to the first year, and to only parts of it. Thus the students keep their cynicism separate from their idealistic feelings and by postponement protect their belief that medicine is a wonderful thing, that their school is a fine one and that they will become good doctors.

The sophomore year does not differ greatly from the freshman yean Both the work load and anxiety over examinations probably increase. Though they begin some medical activities, as in their attendance at autopsies and particularly in their introductory course in physical diagnosis, most of what they do continues to repeat the pattern of the college science curriculum. Their attention still centers on the problem of getting through school by doing well in examinations.

During the third and fourth, or clinical years, teaching takes a new form. In place of lectures and laboratories, the students' work now consists of the study of actual patients admitted to the hospital or seen in the clinic. Each patient who enters the hospital is assigned to a student who interviews him about his illnesses, past and present, and performs a physical examination. He writes this up for the patient's chart, and appends the diagnosis and the treatment that he would use were he allowed actually to treat the patient. During conferences with faculty physicians, often held at the patient's bedside, the student is quizzed about items of his report and called upon to defend them or to explain their significance. Most of the teaching in the clinical years is of this order.

Contact with patients brings a new set of circumstances with which the student must deal. He no longer feels the great pressure created by tests, for he is told by the faculty, and this is confirmed by his daily experience, that examinations are now less important. His problems now become those of coping with a steady stream of patients in a way that will please the staff man under whom he is working, and of handling what is sometimes a tremendous load of clinical work so as to allow himself time for studying diseases and treatments that interest him and for play and family life.

The students earlier have expected that once they reach the clinical years they will be able to realize their idealistic ambitions to help people and to learn those things immediately useful in aiding people who are ill. But they find themselves working to understand cases as medical problems rather than working to help the sick and memorizing the relevant available facts so that these can be produced immediately for a questioning staff man. When they make ward rounds with a faculty member they are likely to be quizzed about any of the seemingly countless facts possibly related to the condition of the patient for whom they are 'caring'.

Observers speak of the cynicism that overtakes the student and the lack of concern for his patients as human beings. This change does take place, but it is not produced solely by 'the anxiety brought about by the presence of death and suffering'. The student becomes preoccupied with the technical aspects of the cases with which he deals because the faculty requires him to do so. He is questioned about so many technical details that he must spend most of his time learning them.

The frustrations created by his position in the teaching hospital further divert the student from idealistic concerns. He finds himself low man in a hierarchy based on clinical experience, so that he is allowed very little of the medical responsibility he would like to assume. Because of his lack of experience he cannot write orders, and he receives permission to perform medical and surgical procedures (if at all) at a rate he considers far too slow. He usually must content himself with 'mere' vicarious participation in the drama of danger, life and death that he sees as the core of medical practice. The student culture accents these difficulties so that events (and especially those involving patients) are interpreted and reacted to as they push him toward or hold him back from further participation in this drama. He does not think in terms the layman might use.

As a result of the increasingly technical emphasis of his thinking the student appears cynical to the nonmedical outsider, though from his own point of view he is simply seeing what is 'really important'. Instead of reacting with the layman's horror and sympathy for the patient to the sight of a cancerous organ that has been surgically removed, the student is more likely to regret that he was not allowed to close the incision at the completion of the operation, and to rue the hours that he must spend searching in the fatty flesh for the lymph nodes that will reveal how far the disease has spread; As in other lines of work, he drops lay attitudes for those more relevant to the way the event affects someone in his position.

This is not to say that the students lose their original idealism. When issues of idealism are openly raised in a situation they define as appropriate they respond as they might have when they were freshmen. But the influence of the student culture is such that questions which might bring forth this idealism are not brought up. Students are often assigned patients for examination and follow-up whose conditions might be expected to provoke idealistic crises. Students discuss such patients, however, with reference to the problems they create for the student. Patients with terminal diseases who are a long time dying, and patients with chronic diseases who show little change from week to week, are more likely to be viewed as creating extra work without extra compensation in knowledge or the opportunity to practice new skills than as examples of illness which raise questions about euthanasia. Such cases require the student to spend time every day checking on progress which he feels will probably not take place and to write long 'progress' notes in the patient's chart although little progress has occurred.

This apparent cynicism is a collective matter. Group activities are built around this kind of workaday perspective, constraining the students in two ways. First, they do not openly express the lay idealistic notions they may hold, for their culture does not sanction such expression; second, they are less likely to have thoughts of this deviant kind when they are engaged in group activity. The collective nature of this 'cynicism' is indicated by the fact that students become more openly idealistic whenever they are removed from the influence of student culture - when they are alone with a sociologist as they near the finish of school and sense the approaching end of student life, for example, or when they are isolated from their classmates and therefore are less influenced by this culture.