The Right Stuff We don’t pick astronauts solely on the basis of their engineering abilities; why do we pick the people who serve us in our direct emergencies on the basis of their college testing abilities? One of my doctor friends \(yes, some of my best the best hospitals in the country, and he despairingly complains that few of these young doctors, for all of their good grades and knowledge of the facts, have been trained at all in diagnosis, in figuring out probabilities under pressure and within a very limited amount of time, with only a paucity of evidence and a few vague complaints from a patient to go by. Whether or not the medical school does train its students in diagnosis, admit or not to admit a particular student is made with no reference whatever to this critical ability. Indeed, most of the students I see at UT are not only untrained in, but are disdainful of such uncertain arts, preferring to prove their abilities in the cut-and-dried theories of lower-level science courses. Many of them avoid the humanities and ‘interperative’ disciplines altogether, and, the medical schools and the AMA dismissed them out of hand. `Objective’ Recommendations This leaves the letters. Arrowsmith’s doctor would not be considered sufficiently “objective.” College professors like myself are so considered, and for that reason every spring we are deluged with requests for recommendations. The typical student will have at least a B and probably an “A” average, but oddly enough, he or she is one of those faces you’ve rarely seen before. Granted, classes at the University of Texas are too large, but as often as not the student has made little effort to get involved with either the class or the people in it. Occasionally they tell me how much they want to “do medicine”; more often they say that they want “to be doctors,” and most of them don’t see the difference. My first inclination is to decline, and often I do, explaining that I couldn’t write a strong letter of recommendation without knowing the student better. The reply, too often, is “But you know me better than any other professor I’ve had here.” So much for “objectivity.” And so, when I can, I write, knowing full well that the vocabulary for such letters has now come to equate “excellent” with “OK” and “good” with “don’t even consider this one.” “Competent” means “dull and not very likable,” and “independent” raises the red flag, “troublemaker.” I wonder what such letters can mean to the members of an overworked admissions committee who have to choose a hundred or so from this army of faceless candidates, all with tediously consistent “A” averages and each armed with two or three equally meaningless letters and an impressive but not overwhelming score on a test that ultimately tests very little, if anything, of importance. The End of the Process So what? Admission to medical school is but the first in a long hard process that can often last ten years or more. The truth is, this is the definitive step. Doctors, in effect, are licensed for life. Interns, with a little sleep, are virtually certain to become full-fledged doctors. \(Technically, they are full-fledged docof success is far higher than the possibility of failure. Only a few flunk out; a few are asked to leave for nonacademic reasons. Given the guild nature of the profession and the expense of even the first terms of medical education, all the pressure is to encourage success, even to the point of nursing along weak or imcompe tent students. And what this means is that once a student gets into medical school on the basis of the most dubious criteria, the selection procedure is almost over. When I was in medical school there were three students at least the class clowns \(insofar as that can be an involpetent. I don’t mean subtly faulted socially stupid, illiterate, or glowing with the charm of a tissue specimen I mean the most simple tasks. They didn’t just give the wrong anwers; they answered the wrong questions. They didn’t just miss the vagus nerve; they cut through it. They didn’t only fail to find the mitochondria in their slide preparation; they consistently ground down the lens of the microscope right through the slide. They are all doctors now specialists, of course. One of them, now a gynecologist, used to visit the undergraduate library during lunch, to peek up the co-eds’ skirts. Another had a doctorfather, on the board. These are special cases, of course, the few frightening exceptions in every profession who can be used by the unscrupulous investigator to cast aspersions or worse on the whole profession. But were they exceptions? Not in this sense: they usurpted candidacy for that much admired and coveted degree from someone who would have been much better. consequently, \(complains my same friend, who was a German major in colof dealing with the most typical office or hospital situations. They are, simply, the wrong people for a most important job. Even diagnosis alone won’t do it. There is some call for “bedside manner” even in an auto mechanic, who has to give advice and tell a not entirely calm customer what is wrong and how it is to be fixed. In a physician, no matter how sophisticated the science, this is of course the ultimate necessity. Throughout history, quacks have succeeded and won the confidence of patients where scientists have failed, and no small number of Americans have displayed their preference for the former, given the personalities of too many of the latter. But this is no coincidence either. I have already mentioned that my pre-medical students tend to be uninvolved with the class. They are rather concerned, as they would more flatteringly put it, “with the material” \(that is, fession of monstrous scope; they are, to use a piece of current phychological jargon, “material-oriented,” not “peopleoriented.” They prefer facts to dialogue, explanations to sympathy and understanding. They enjoy the “hard facts” but eschew “mere opinions,” despise sentimentality and feeling. This might be acceptable in a surgeon, but most of these students express an interest in medicine, even in psychiatry. Contrasted with these, however, is another group of students we all know quite well. They tend to be dedicated humanities students with respectable grade-point averages. They genuinely want to “help people,” but inevitably fall behind the more ruthlessly competitive students who live for their grades and stick to their required subjects. Typically these more humanistic students have extensive hospital experience as unpaid helpers or volunteers in clinics, but they find it much harder, if not impossible, to get into a decent medical school, given the current criteria for admission. For the simple fact is that the virtues we all praise in a doctor have been neglected if not lost in the professionalism of modern medicine. Kindly Arrowsmith and the physician who so inspired him today would have no place in the medical establishment, not because they would not fit in and not because there is a professional conspiracy against them, but simply because today they don’t have the right stuff to get into medical school. So, “whatever happened to the old family doctor?” He never got admitted in the first place. THE TEXAS OBSERVER 9
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