The short white coat, breast pocket full of colorful pens, side pockets bulging with gauze pads and suture kits, a simultaneous look of bewilderment, excitement and fear. Pathognomonic signs of the third-year medical student on wards. Third year of medical school is a period of learning how to diagnose disease, treat patients and understand what it means to be a doctor in this health care landscape. There is not enough time in the mere weeks you will be rotating through a clerkship to master all the literature, so you utilize the necessary resources for success, while hoping the rest diffuses into your consciousness. The skull is conditionally semipermeable to information.
If you have not worked in health care prior to joining medical school, learning the hospital ecosystem is another uphill battle. Days before I wrote this, observing a colonoscopy, I asked a nurse anesthetist, “What is this white stuff in the syringe?” She replied, “You don’t know Propofol? The Michael Jackson drug?” Sometimes I envy many of my colleagues who were nurses and hospital techs in a past life; they have an upper hand in the game already. With all these unknowns, we are left in a chronic state of deficiency, in knowledge and practical skill. But being the OCD-ridden, type-A people we tend to be, we incessantly have the need to rectify this deficiency. It never ends. The cycle repeats in residency, fellowship, and sub-fellowship. But that is not the issue I have with this profession. My gripe is when I notice the effects of this culture on our involvement as medical trainees and professionals, in the health care discussion.
While being painted with the brush of ignorance on a daily basis, and our incessant need to know everything about everything, we deny ourselves some of the basic curiosity on how health care is run, where it is struggling and — most importantly — what we can do about it. If I had a dollar for every occasion, I heard, “Medicine is run by businessmen,” I would still be in debt, medical school loans are no joke. But when America’s neurosurgeon felt “more qualified” to run Housing and Urban Development rather than Health and Human Services, you must smell the irony. Everyone will offer their take on why there is so few physicians heading major policies in health care; some make sense and others do not.
One I think is particularly true is that the temperament for practicing as a physician is not particularly conducive to making decisions based on revenues, capital losses, and market shares. It is quite a leap to go from making decisions for Joe’s chronic kidney disease, to overseeing coverage for diabetes and hypertension screening to prevent said CKD. But that is exactly the problem; we think we must make this leap in one bound. Picture the most influential CEOs today, how many were thrust onto a platform that was not preceded by decades of preparation? Was there a steep learning curve? Probably. Were they under the illusion that they knew everything about their business? Probably not. It is acceptable in business and in most other arenas. But when it comes to medicine, it is a dreaded answer, an indictment of incompetence, a sign of relegation to lower ranks of the ladder. Next time you are in a team of residents and fellows, keep a count of how many times “I don’t know” is uttered. I guarantee you, an inverse correlation between seniority and this type of vernacular exits (P-value < 0.05).
Medicine is hierarchical, and as a medical student, you are quickly made aware of your place in the hospital. But what do we do when we are made to feel this way? We clam up, involute, and come down on ourselves. We surmise it must be our clear lack of knowledge and skill, because it surely cannot be the 2 hours we spent to master a skill that requires 300. So, after enough times facing the angry lion, we adapt to the system, and sacrifice curiosity, for fear of being shamed. But more than shame and scrutiny, I fear we are becoming conditioned to keep silent in matters that we are remotely knowledgeable. As a result, we exile ourselves from issues that we feel unqualified to discuss like public health, health policy, and health care reform.
Despite my proximity to health care, it has proven to be an enterprise I know very little about. I find it difficult to reconcile how we claim to put patients first, but also consider their health insurance if any, how good it is, and what services it covers. I fundamentally do not understand how one can legitimately claim no conflict of interest when insurance companies and pharmaceutical groups essentially purchase monopoly of territories. All these entities exert influence. And this influence may supersede what is best for one individual patient. Perhaps naïve and simplistic concepts coming from an amateur. But then I ask you, how many expert physicians, and authorities, are asking these basic questions?
The truth is, not knowing something is fine. We should not fear acknowledging ignorance because it makes us look or feel bad. Full disclosure, it took about nine months of clinical clerkships to acquire this piece of wisdom. I would rather admit ignorance today, work on my deficiency tonight, and return tomorrow looking for more opportunities to become ignorant again. What I will not do, is compromise my curiosity to understand fundamental issues in my environment, even if I am not expertly qualified to tackle them yet.
Mohammed Ahmed is a medical student.
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