The hidden curriculum of medical school can be overwhelming and unforgiving


I met Mr. B during my week on the endocrine service of my internal medicine rotation. My attending told me we were being consulted for this patient’s high sugars and a foot ulcer, and asked me to take the history.

I walked into Mr. B’s room and was immediately struck by its stench. Mr. B had undergone a resection of his bladder tumor the day before and as a result was severely incontinent. He had not showered in weeks and had an infected diabetic foot ulcer that was overwhelmingly purulent. Reminding myself of the two weeks of bad smells I had already survived on vascular surgery a few weeks earlier, I donned gloves, threw on a smile, and greeted Mr. B.

When I asked how he was doing, he looked at me quizzically and responded, “I’m fine – why wouldn’t I be?” As I continued my interview, Mr. B was hardly able to answer any of my questions. He knew that he had diabetes but was unsure when it was diagnosed, what type of diabetes it was, and what medications he took regularly. He did not know what other medical conditions he was being treated for. He did not know when he had developed a foot ulcer and, in fact, had forgotten he even had one.

I was a bit taken aback as there was no mention of altered mental status or baseline dementia in Mr. B’s chart. With each question, I grew more confused and more frustrated. Eventually, I resolved to gathering as much information from his chart as possible and thanked him for talking to me. I was about to leave the room when he added, “You know – three out of my five children died this year.”

I paused. I knew I now carried the responsibility of this man’s suffering. I knew I needed to take a more detailed social history and to screen for depression. More importantly, I knew I needed to listen and to respond with compassion.

Yet somehow, in this moment where this man had showcased his vulnerability and shared his suffering with me, a complete stranger to him, all I could think about was how alone I felt. How I simply could not handle one more tragic story from one more patient I felt I could not help. As I continued to listen, I mustered up as much empathy as I could – but emotionally, I went numb. And when I later reflected upon it, I felt ashamed.

Going through the third year of medical school is jarring and almost stunning. In retrospect, the first and second years of medical school are almost protective. With the primary responsibility to study all day while soaking up as many facts as possible and the luxury of a highly flexible schedule, you are protected from the harsh working hours, responsibilities, and insecurities of working in a clinical environment. You are also protected from the fear, grief, anger, and tragedy that patients carry with them to the hospital and the clinic.

When beginning the third year, almost overnight you are charged with the harsh responsibility and privilege of facing these realities head-on daily. You lose any sense of control of your time and are at the beck and call of your residents and attending physicians, with the constant awareness that you are at the bottom of the totem pole. You are aware that you are constantly being evaluated, and also painfully aware that your lack of clinical experience makes you more of a burden than a help to the health professionals who are actually taking care of patients.

Most of all, you learn that the hidden curriculum of medical school can be overwhelming and unforgiving. Many patients are not grateful for your care, many patients have conditions that you cannot treat, and many patients are the victims of injustices you cannot solve. You learn that you have to care the “right amount” – enough to make your patients feel acknowledged and understood, but not so much that you are unable to reset when you inevitably have to walk into the next patient’s room with a smile a few minutes later. In a way that is distinct from your preclinical training, you learn what it truly means to be physically, mentally, and emotionally exhausted – and you learn how to move past it.

On this particular day when I met Mr. B, I was exhausted. The night before, my patient, a single mother in her 40s that I absolutely adored, was told that she had metastatic lung cancer. That morning, my young patient had told me to “get the f– out” when I walked into her room before beginning to violently thrash because she “did not want to talk to anyone” about the episode of diabetic ketoacidosis that had just almost killed her.

As a doctor, it will be my job to absorb and effectively respond to any circumstance my patients throw at me, but as a third-year medical student, I am only beginning to understand and grapple with the full spectrum of humanity I will be expected to serve every day. I am only beginning to understand the delicate balance between caring too little and caring too much.

It is in moments such as my conversation with Mr. B where I feel the most alone, as I am forced to reconcile the image of the doctor I have always wanted to be with the doctor I believe I am becoming. It is in these moments where my love of people and stories and my gratitude for the opportunity to serve others become paramount. It is in these painful moments where I believe I truly grow.

When I returned to the hospital the next morning, my attending physician asked me to follow up on my patients from the day before. I popped into Mr. B’s room, but this time I pulled up a chair, and in addition to asking my standard medical questions, I asked him if he felt sad about his family. He told me he did, launching a ten-minute conversation about his struggles. Though he was still confused and much of the conversation was twisted and undirected, I believe that he felt relief in being afforded the opportunity to speak freely.

When I left the room, he chirped, “Thank you, sweetie!” and in spite of the pain and the exhaustion and the grief, I smiled, leaving the room with my head held a little bit higher.

Prerana Chatty is a medical student.

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