Friday Reflection 11: Physician Acculturation: Knowledge, Responsibility, Experience and Humor

This one got a little long, bear with me (the last line is even kind of funny).

TP was a 67-year-old man with recurrent diverticulitis admitted to the hospital for a left hemicolectomy. He was admitted before his surgery so that he could come off warfarin and be bridged with heparin.

I was sitting on the M15, the Second Avenue bus from 70th street to 34th street, when I noticed my hands. I was a first-year medical student at the time, going home to grab Sunday dinner with my parents. I sat staring at my hands, flexing and extending my wrists and fingers. Pronating and supinating, abducting and adducting. If any of my fellow passengers noticed me, I expect they thought I was either psychotic or tripping. For the first time in my 22 years, I understood how my hands worked. Where the muscles originated from and where the tendons inserted. Which nerves innervated which muscle and how that nerve formed in the befuddling brachial plexus. I now knew something that I didn’t even know I didn’t know a month earlier; before I started taking gross anatomy; before I started dissecting a cadaver. I was acculturating.

Although acculturation usually describes the process of an immigrant adapting to a new country, it happens anytime someone enters a new culture. Assimilation, separation, integration and marginalization are strategies of acculturation.

When we train doctors, we strive for assimilation and integration. We want people to assimilate, to “adopt the cultural norms” of medicine. These norms are what we consider medical professionalism. Recently, we have also wanted people to integrate. We want trainees to “maintain their culture of origin” not only because we recognize the benefit of doctors better reflecting our country but also because we want them to retain what makes them individuals. We hope trainees retain the empathy, the breadth of interests and the intellectual curiosity that made them attractive medical school applicants. Failure to acculturate is not compatible with a successful, or at least a happy, career in clinical medicine.[i]

What is necessary for acculturation into medicine? There have been a few pieces dedicated to this question. Forgive and Remember is a classic sociology text that describes the process in surgical training. A paper published in the NEJM in 1993 examined written reflections of 3rd year medical students looking for stages of acculturation. I’d suggest that there are four aspects that mark the entry into the medical guild: knowledge, responsibility, experience and humor. Such markers are not unique to medicine. Police officers, professional athletes, accountants and just about any other professional could identify their own unique signs of acculturation.

Before Acculturation: Filtering

Members of a profession don’t behave as they do only because they have been acculturated. Filtering takes place before acculturation. People are filtered out of the pool of applicants passively (because they lack interest) or actively (because they are found to be unacceptable). Ideally, this filtering excludes those unlikely to acculturate successfully. What filters precede medical training? People who lack compassion or shy away human connection are not attracted to medicine. The profession also demands some degree of smarts and sacrifice -- we expect an applicant to be able to put his or her bottom in a chair and study and learn. The applicant must be able to delay gratitude, not just pass up a marshmallow for 15 minutes but eschew free time and income for years. Filtering is not always equitable or efficient; medicine excludes many promising students. For years, our field filtered out people based on their gender or skin color. Currently, family income is a well-documented filter.[ii]

Knowledge

What I was appreciating on that bus 33 years ago was a first step in acquiring a knowledge set unique to physicians. There were other, even more memorable instances. I was once studying for the bacteriology exam in my microbiology course at a local coffee shop.[iii] I was flipping through flash cards. I stared at one side of a card on which I had written the single word: Plague. I concentrated, trying to remember what I’d written on the other side. When I flipped the card, I heard a voice from behind me.

“I’ll trade you a Clostridium botulinum for your Yersinia pestis.”

I turned around to see an older man in a white coat, grabbing his own cup of coffee. With a kind smile he said, “Good luck, you’ll do fine.”

Part of the enjoyment and camaraderie that accompanied studying for major tests was the understanding that we were completing a rite of passage.

While a catalogue of knowledge is part of the acculturation into medicine, a way of thinking -- a mindset -- is part of the acculturation into a specialty. All of us in medicine share a knowledge base, but a general internist approaches a problem differently from a surgeon or preventative cardiologist. Talking through cases with a group of general internists can feel to me a bit like reminiscing with the guys I went to summer camp with – comfortable and natural. These are members of my tribe.

Responsibility

TP was a patient assigned to me during my surgical clerkship after he was admitted for a hemicolectomy. He had had a stroke a few years before which left him with a mild right facial droop. At the time of the stroke, he was diagnosed with atrial fibrillation and started on the blood thinner warfarin. He had experienced a transient ischemic attack about a year later, while he was off warfarin for a dental extraction. In the 18 months before this admission, he had suffered through multiple bouts of diverticulitis and, with the counsel of his internist and surgeon, had decided that it was time to part ways with his troublesome distal colon. He was admitted a few days before the planned surgery, taken off his warfarin and placed on heparin, to be stopped about 4 hours before his surgery so his blood would be able to clot appropriately during his operation. After the surgery, we would restart the heparin when we thought it safe, restart the warfarin, and discharge him on warfarin alone once his level was therapeutic.

Because he was “my patient,” I was with TP as we turned off the heparin and I waited with him to be called to the operating room. The case before him was complicated and TP’s surgery was delayed. As the hours ticked by, he and his family became increasingly frantic, absolutely convinced that this delay would lead to a stroke. I called the OR and was told: he would be in surgery in 3-4 hours; it was perfectly safe for him to remain off heparin; and it was my responsibility to assuage the concerns of TP and his family – however I should call if anything actually changed. The weight of this responsibility was like nothing I had experienced. I felt like this man’s life was in my hands. The responsibility became nearly unbearable when the family thought they noticed his facial droop was worsening. (It was not. He eventually went to surgery and did perfectly well).

This was the first taste of responsibility that would grow throughout training. In short order, I would be the one responsible for:

drawing the blood for all of our patients;

ensuring that no results were overlooked;

confirming that no call went unanswered;

breaking the bad news;

making the decision that continued care was futile;

pronouncing the patient dead.

There are certainly people in other professions who have as direct responsibility for the welfare of others – often even more immediately – bus drivers, train engineers, airline pilots. I’ve talked to people in these jobs. Some feel the weight of this responsibility, some don’t, just as in medicine.

Experience

The experiences you share with others in your field, your brothers and sisters in arms, bond you to your colleagues – past, present, and future. This is true with any acculturation. Whether the experience is a trip to Washington DC, basic training or internship, a common history is powerful. What you sacrifice during your entry into the field, might be an important “negative experience” in acculturation. I discovered one indicator of my sacrifices a few years back when I constructed a histogram of my favorite albums, arranged by year.[iv] On this list, there is a striking paucity of records released between 1987 and 1996, the decade of my most intense medical training, when I was getting my 10,000 hours of experience rather than listening to music.[v]

Dark Humor

Humor at the expense of a patient in abhorrent. It is antithetical to the mission of a healthcare worker to laugh at one who is suffering; one who is (at least temporarily) less fortunate; one who requires care. It is unprofessional, cruel and, fortunately, exceedingly rare.

There is, however, acceptable humor in medicine. The humor is often dark and usually defensive – whistling by the graveyard. We laugh at the hopelessness of situations in which we find ourselves. We laugh when it seems like an evil god is making our job impossible. We laugh to protect ourselves from the knowledge that we will inevitably occupy the hospital beds on which we round.

Dark humor among physicians does not rise to the level of knowledge, responsibility and experience as markers of acculturation. Not all physicians participate or enjoy this type of humor. However, I do think this humor is something unique that physicians share and (can) appreciate.

I find myself chuckling, practically through tears, when I go to document a note for a visit in which a patient and I discussed referral to hospice and Epic has reminded me that the patient is due for an “Annual Medicare Wellness Visit.”

My team and I laugh when our patient has a fever. For the last 2 weeks, we have worked day and night (literally day and night) treating 4 different serious medical problems, arranging for transfer to a rehabilitation facility that all members of the family agree is acceptable, supporting the patient devastated by their newly diagnosed illnesses. The fever means that there will be no discharge.

I’m not sure I have laughed harder than when, after a month of work on a gastroenterology consultation service during residency, our attending took the team out for a very nice lunch at the Isabella Stewart Gardner Museum. As our appetizers arrived, he passed around a handout about intestinal gas and proceeded to deliver a lecture on this topic. Not only did I enjoy the lunch that accompanied the talk and the humor but I learned things that I still use to counsel patients.

I now give the acute diarrhea talk to our third-year students. In this talk, I use my own bouts with intestinal challenges as the illustrative cases. The title of this talk? “Acute Diarrhea: A Personal Journey.” I generally give the talk right before lunch.

Sometimes we share harmless humor in an inappropriate place, where our laughter can be witnessed and misinterpreted. This is unprofessional. In addition, humor in medicine needs to come from a place of caring. Humor in medicine without compassion gets you House of God – a book I have started three times and have never been able to finish.

When an immigrant acculturates into a new society, the change is pervasive. Professional acculturation is less encompassing but the changes do affect one’s life outside of the clinical arena. Knowledge affects how you look at other people, their health, their behavior. It also affects our language: I recently referred to the “malignant behavior” of a colleague and discussed the “differential diagnosis” for the Hamilton/Verstappen flip at the top of Formula 1. I like to think that the sense of responsibility makes us better people in the rest of our lives and that our experiences prepare us for the traumas that life has in store. The dark humor has served me well for getting through trying times and in counseling dying relatives and friends -- I am often able to go where they want but to where others are afraid to go with them.

Because the culture on medicine is flawed, our acculturation can be harmful. Our knowledge may cause health related anxiety. Our sense of responsibility at work can make us neglect our responsibilities at home or shun people who fall short of our sometimes unreasonable expectations. Our willingness to sacrifice can make us prone to accept working conditions that threaten the welfare of our patients and ourselves. My dark humor has, on occasion, silenced a dinner party.

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[i] Prepare for a David Foster Wallace-esque footnote. Acculturation defined by separation occurs when an immigrant, remains in a cultural enclave, physically inhabiting a new country while rejecting the culture. In professional training, this would mean remaining in your own cognitive enclave while rejecting the culture of medicine. When I recall trainees whose acculturation was defined by separation, I think of people who ultimately failed to complete their training or went on to be lonely and unhappy in their careers. I have never seen a student, whose acculturation strategy was marginalization -- leaving behind his or her own culture while rejecting the medical culture -- complete training.

[ii] Click on “download report” and look at the first graph here.

[iii] To date myself, this was a shop on the corner 70th and York where you could get a cup of coffee and chocolate chip cookie for $1.00.

[iv] Please, no comments about the nerdiness of this activity.

[v]  I’m assuming that the quality of musical releases didn’t decline during those years.