Harvard Medical School, The Not Too Distant Future

Commander of the Devout

Like all good medical students, I await the arrival of the Mother Ship as promised and foretold by the Prophets in whose names we have dedicated our lives. But I have begun to doubt. The world goes on beyond the walls of our medical school. I catch brief glimpses of it over the razor wire that our robed masters say is to protect us from The Deceiver. Sometimes it’s an automobile of an unfamiliar type. Occasionally it’s just a snatch of sound, a few notes from what I once remembered as an ice cream truck although the taste of ice cream eludes me. It is haram, or forbidden, to the disciples and I have not tasted it since my parents handed me to the Guardian at the gates of the adminstration building whose threshold I have not crossed for these many long years.

I was not destined for medical training. Some even doubted my dedication during the selection process. My grades and test scores were good, of course, as are everyone’s who is chosen to follow The Way. And it goes without saying that I had a medical degree from a third world country. Everybody does. It’s considered the bare minimum to prove your dedication to the Prophets. But I never really demonstrated my desire to be a physician, at least not where it counts. I amost cured small pox. I almost implemented a Single Payer System (Peace Be Upon Its Holiness) during one whirlwind summer in Tajikistan. I almost did this and I almost did that, never gaining a foothold, something that could convincingly show my dedication to medicine.

Even my admission novel wasn’t as long or as original as it should have been. I only worked on it for five years and the final product, while servicable and the recipient of several literary prizes was not considered Nobel material.

So I sometimes catch the disapproving glances of my fellow medical students. They whisper that I had some help gaining admission. Perhaps a relative on the admission comittee, maybe a few well placed donations to the High Professors.

“Empathy and Caring” Intones my novice, a first year, breaking me from my reveries.

“For the Underserved, now and forever,” I reply automatically, the words of the ritualistic greeting coming easily to my lips though I no longer believe them.

Even during my first encounter with one of the Holy Underserved, though carefully supervised, the brief glimpse I had of her through the Hippa curtain did not inspire the pure thinking in which I had been instructed. She was incredibly fat and reeked of cigarette smoke. Neither had she bathed in a very long time and she smelled like a piece of rancid cheese. I knew on an intellectual level that this wasn’t her fault. After all, are not the secrets of soap kept from the Underserved? And yet I resented her and fought with all of my training to keep from betraying my revulsion to the Guardians.
My novice looked at me suspiciously. Have I betrayed something on my face? Have I allowed my carefully cutivated external serenity to slip?

“The Commander of the Devout wishes to see you, oh my Fourth Year Brother,” says my novice softly, barely concealing his anger to have been assigned a Fourth Year who is fallen from the favor of The Prophets.

“So it shall be done.” I dismiss my novice who scurries away to his empathy prayers and begin the long climb to the chambers of the Dean of Students.

The Commander of the Devout turns from the window and motions for me to sit down.

“I have had complaints,” he says quietly, looking at a thick file laying open on his desk, “Some even question your faith.” The Commander is known for coming quickly to the point. During rounds he once cut short a resident who had only been discussing a patient’s potassium for thirty minutes.

“I serve the Holy Underserved in the wilderness of health care access,” I blurt out, hoping to buy time to collect my thoughts.

The Commander waves his hand inpatiently. “Let us dispense with the scriptures. You obviously don’t believe them, or at least that’s the impression I get from reading your weekly evaluations. Did you not roll your eyes on several occasions during your primary care appreciation meetings? Have you not said to several of your fellow students that you had considering radiology? Don’t deny it. I can produce witnesses if required.”

“I try to think pure thoughts, Emminence, but of late my mind wanders and I wonder what it would be like to have some time to myself, to think of other things besides medicine.”

“Time for yourself? You blaspheme here in my presence? Is it not written that our fathers fled into the wilderness to escape the uncleanliness of the eighty-hour work week?” demands the Commander, making the the warding sign, “Did not the infidels match into dermatology and consort with opthalmologists jeapordizing their very souls and keeping the Pure from the Rendevous With the Primary Care Mothership in the End Times?”

I have never seen the commander so angry.

“Do not fall for the traps of the Deceiver and his Arch-Devil, the Dark Lord of PM&R whose task it is to lead the Faithful astray and deny the Holy Underserved free access to health care and their just absolution from all earthly responsibilities.”

“I have in my hand the results of the match and I could not help but notice you have matched into Emergency Medicine,” the commander spits out the words as if they taste bad, “But I say unto you that even at this late hour it is not too late to withdraw and fall into the welcoming bosom of Family Medicine, the One True Specialty. To sojourn among the unclean, and certainly their are none as unclean as the Emergency Physicians who as they know not empathy and make cruel jests must surely sit at the right hand of the Deceiver as chief among the damned, to sojourn among them is to fall away from grace precipitously and permanentely.”

I shift nervously in my chair. I have been discovered. My involvement in several primary care interest groups and the oaths I have sworn have been in vain. Have I been so transparent? I say nothing.

“Go then,” intones the Commander of the Faithful, “But know now that you are shunned and for any to speak to you is haram.”

Graduation can not come soon enough.

25 thoughts on “Harvard Medical School, The Not Too Distant Future

  1. Brother, are we in the same remote monestary? Your story contains far too many similarities to my own. Perhaps our attempts to maintain our true devotions under cover of darkness for fear of discovery have have obscured all of us from finding one another. I believe it is time we organize…. -SM

  2. Thank God! I LOVE this post, it says it all about how group prejudices/judgements prey on the struggling apprentices of the profession.

    How would healthy, responsible, smart people with a sense of humor, good interpersonal instincts, excellent memory, and compassion crowd in droves to such a jungle?

    Answer: not happening enough.

    I love the hippa curtain.

    I’m going to open my own walk-in clinic in the next few months, with a sign in reception, next to a big ficus tree:

    “unless you are having a health emergency, please remember to shower and wear clean clothing to your clinic visit.” (and, unstated, refrain from smoking until the exit door is closing behind you….)

    And another sign which says:
    “unless you are having a health emergency, we have a 60$ convenience charge for our walk-in service which is due prior to seeing the doctor. Costs of any recommended bloodwork or imaging tests will be a charged seperately and you will be provided with an estimate of such charges in advance. If you have insurance, feel free to take up the question of your reimbursement for your medical expenses with your insurer.”

    and another sign:

    we offer
    saliva HIV tests
    drug screening for your teenagers

    we sell SNUs tobacco mini-pouches and recommend them over smoking

    Doctors just don’t set the tone creatively enough.

    I can’t wait for CLIA-waived CBCs to hit the market. CMPs are already available.

  3. Maybe it’s because I’m not at HMS, or because I’m only one year into med school, but honestly, I haven’t felt any pressure from the administration (or anyone) to go into primary care. It’s not an issue. If anything, the prevailing attitude seems to be, “find the best fit for you.”

    Come to think of it, I’m surprised that *any* med school would push students into primary care. Med schools depend on alumni for donations, and specialists will almost always be in a position to donate more that PCPs. In any case, it would always make sense to prepare your students well to pursue whatever dreams they may have. Satisfied students are more likely to become satisfied (and generous) alumni.

  4. Yeah, there’s not really any pressure at my school to do primary care. The primary care interest groups are probably better funded, because they know they need to recruit. The only pressure is the fact that the military match is pretty much inflexible. EM is the most competitive Air Force residency right now and I basically know it’s unlikely I can get it straight out of med school. I’d have to do a couple of years as an internship (only) trained GMO in order to be really competitive.

  5. Being quite close to a number of HMS med students (and very close to one in particular), familiar with a handful of HMS faculty members, and having worked there for a year, I can assure you that it’s not nearly as bad as Panda puts it. There certainly are people who are very passionate, vocal, and even seemingly fanatical/political about their particular missions, but I don’t think it’s as ubiquitous as the popular media or rumors would have you think.

  6. Yet that abomination pales in comparison to the cardinal sin of securing a poor feedback evaluation from those that might one day procure a position in your “medical home.” As long as the winter grows cold and the sun rises in the east, the piercing anonymous words of Bud the Radiology Tech will haunt you in all future endeavors.

  7. I have had this conversation last week. “Why Allie, do you seem to think the patient should take responsibility for themselves? You are cold and heartless and absolutely (this was my favorite part) middle class about this.” Clearly I wasn’t recognizing my duty as being a ‘healer.’

  8. Enjoyable post, although it seemed to borrow a lot from “The Handmaid’s Tale”.

  9. I’m a 2nd year and there is a lot of pressure for primary care at our school. Many of our small group activities are geared towards primary care. Most of the “guest lecturers” are primary care pimps (PCPs)that would make Joseph Goebbels hang his head in shame.

    Take care Panda

  10. I specifically remember at my med school interview (yeah, I only went to one), talking about how I wanted to do “cradle to grave primary care in a rural setting.” Not that I was lying at the time, but I really didn’t have any idea what I was talking about.

    Now I’m in training to be a high risk obstetrics subspecialist who will be essentially unemployable in any town with a population smaller than 100,000.

    One thing I really do struggle with, sometimes is the issue of poverty. I really thing that really uneducated, poor patients don’t have the same capability to be compliant and take care of themselves as other educated, less poor patients. However! I do think that they can and should try. If I bust my ass to fill out forms so that they can get their glucometer, test strips and lancets for free, and spend countless hours explaining to them in extremely simple language how to use it and why it’s important (“because you or your baby could die if your diabetes isn’t controlled, it’s really important Ms.Sugar”), then the least they can do is to take a few blood sugars. What I don’t understand is why I can’t sweet talk (no pun intended) my diabetics into taking a few damn blood sugars! To add insult to injury? Those diabetics will then sue me when they have a baby with whatever problem or a stillbirth or whatever later.

    I think that evidence of patient non-compliance should be grounds for automatic malpractice lawsuit dismissal.

    Oh, and I want my patients to take a shower before they come to my clinic. Soap is cheap. I would buy soap for patients if I thought it would get them to shower before clinic visits, especially gyn exams.

  11. Is it arrogant/otherwise evil to say that part of the reason the indigent patients are non-compliant is also part of the reason that they are indigent? If you listen to many people in my class, to say such a thing would be hubris. Like Midwife said, there are probably reasons they can’t try to take care of themselves, but they could at least try!

  12. Not to make excuses, but it’s really hard to take care of yourself when you’re trying to scrape together enough money to pay off your new $400 watch, $300 cell phone bill (mostly for the 35 custom ring-tones) and the $1000 custom chrome rims that you just put on your 1991 Civic.

    Alot of times, the indigent aren’t taking care of themselves because they simply are too absorbed in creating the image that they are not indigent, and in doing so trap themselves in inescapable debt. And I’m not saying it out of ignorance or spite, but out of what I’ve seen a couple of times in my own extended family.

  13. Bostonian, how did my Texas inner city students make it all the way up to MA? Because I’d swear that’s who you’re describing! My kids have nothing…*nothing*…and yet they sport better cars and electronics than I do! Image really is so important to them…sometimes it’s all they have, and they have NO idea about what it means to be financially responsible. They have no vision; I imagine that’s hard to find in the environment in which they’ve been raised. They also have no social skills; I can think of many students to whom it would never occur to wash or change clothes before visiting a physician’s office. It is heartbreaking and exhausting, but I do what I can to show them a different view.

  14. Panda, do you have an e-mail address on this blog? I’m a prospective medical student of the nontraditional variety and have a few questions I’d rather not put in comments. Thanks.

  15. Panda,

    I’m becoming a raving fan! You’re too funny. I love the PM&R jibes, “Do not fall for the traps of the Deceiver and his Arch-Devil, the Dark Lord of PM&R whose task it is to lead the Faithful astray and deny the Holy Underserved free access to health care and their just absolution from all earthly responsibilities.”

    But, it’s not always Plenty of Money and Relaxation; sometimes its just Plenty of Misery and Retribution. I hope that our suffering makes you feel better! 🙂

  16. I love it! Actually, this is exactly what I imagine AMSA will be like in a few years.

    At my former med school (a “competitor” to HMS), this could be reversed: primary care and family medicine are looked down upon and the One True Path is 15 years of postgraduate training to become the world’s preeminent expert in anaplastic thyroid cancer.

  17. I’ve broken or snapped something from laughing so hard. Is there a family practioner in the house?

    Panda, I’ll say it again; should the doctoring thing leave you with plenty of free time…ow, ow, ribs hurt from laughing…you must write. For money.

  18. This is hilarious. I may disagree with your political views and stance on the health care system (then again at the moment I am looking forward to a career in FP), but I do respect the point you make.

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