Metamorphosis

KAFKA'S MATTER-OF-FACT style about a bizarre turn of events is eerily applicable to the process of enculturation as a third-year of medical student. No one really knows what he gets himself into at the beginning of medical school, but soon a routine of rigor and discipline emerges. Students plunge into their studies, and as the saying goes, try "to take a sip from a fire hose".

Then The Third Year arrives, with its promise of patient care and application of knowledge so hard won. There is, however, a catch. This new world has its own rules; the hierarchy, the politics, and the evaluations threaten to harden the spirit.

In fact, as we continue to chip away at an enormous body of knowledge, we are often forced to build up our defenses to these surroundings — as in multiple layers of glossy lacquer — to protect ourselves from patient tragedy or from professional scrutiny. (To illustrate: I was told once by an attending that, during a presentation, one should never give credit to colleagues or be in any way humble — it's all about "looking good.") Despite these often counterproductive and superficial trappings, there are stronger undercurrents towing at the student's burgeoning clinical anima that will soon shape him as a physician.

Little by little, small adaptations are made each day during the long hours spent observing experienced clinicians. The initial blind faith of following procedure and protocol slowly internalizes while the pearls cast before us medical students begin to accumulate. We change, perhaps becoming more confident in our abilities and interactions.

However, at times to survive in this environment thick in knowledge, technology, and the human condition, it is tempting to recoil into our evolving professional shell. Like Gregor Samsa, we may risk personifying that which we loathe the most: distance from patients, from each other, and from ourselves.

The key to our development as clinicians is the mentorship we as medical students receive from our attendings and preceptors. They were once taught diligently with the understanding that they would one day in turn pass on the Art. The formalization of medical curriculum is a relatively recent phenomenon, and syllabi and Powerpoint presentations must not replace the sincere connection between student and teacher. Essential to the art of medicine is the ancient process of example, entrusting the torch of learning from mentor to student.

This crucial flame that illuminates through the ages chokes for air. Unfortunately, the practice of modern medicine straps both physicians and students for time. Budgets are re-prioritized, and we medical students may be left to our own devices. We get by, passing our rotations and shelf exams, but the question arises: are we to be "processed" or educated?

This month, my classmates and I will become fourth-year students, busy arranging acting internships, applying for residency, and going on interviews to solidify our career paths. Soon we will be busy interns, running to stand still. As I reflect on this year and look to the next, I have a sense that it is vitally important for both students and faculty to be keenly aware of the metamorphosis that we undergo in medicine.

It can be a rewarding, enriching experience that challenges us to become better people through our interactions with patients and each other. It can, however, take on a more insidious nature, that of a white chitin shell that isolates us. As students this shell takes the form of the white coat with all of its connotations and expectations; in physicians the longer coat, with its associated greater responsibility, threatens to be even more restrictive.

So what began as a reflection on my experience has evolved into a plea. To those physicians practicing in academic centers or in the community: take the extra time to answer your students' questions fully, show them how to do a procedure that may have long ago become commonplace to you, or better yet point out to them the pearls that were once passed on you by your mentors. We yearn for the mentoring relationship that was once habitual. If you do not work with students often, consider having a student shadow or rotate with you.

To my fellow students, let us remember that the process of becoming a physician is a great privilege, and that we must avoid our own personal shells to embrace the patients we care for and the profession we have chosen.

As this new academic year begins, we all should be making an investment not only in our education and professional enrichment, but also in the quality of our relationships. It is only through our connection with each other that a truly constructive and therapeutic environment is possible. We students need and seek the help and example of the faculty to emerge from our notecard-lined cocoon as something better than the common bug.

tahoreczko@ucdavis.edu

1. Kafka had a rough relationship with his father, and for much of his life was miserable at home and in society, finding both oppressive and abusive. Samsa works a dismal job and lives in his father's house, in a windowless room with two doors opening to other parts of the house. (No privacy and no direct connection to the outside!) He wakes one morning as a huge cockroach. His family tries to adjust, but in time abandon him. He's just a cockroach. He always was, of course, but in human form. At last he starves to death and is thrown out with the garbage. - J.L.