36 Comments

Wow! That just may be the most well written post I have read! I'll have to read it several more times to thoroughly absorb it but you certainly made me better understand the responsibility that comes with being a physician. I can't imagine. Tremendous stress but also very gratifying. Most doctors seem reluctant to share their feelings it seems because they want to seem all-knowing for lack of a better word. You do not. Thank you Adam (Rocky to me:) Keep doing what you're doing! Sabrinalabow.substack.com

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Have you considered changing the name of your talk to "A Cute Diarrhea"? Just a suggestion of how to make it more fun.

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Dec 14, 2022Liked by Adam Cifu, MD

Thank you, we nurses have a dark humor as well- cope comes in many forms, I am thankful this is a common one.

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More like the Dark Ages. Not just music. Movies. Friends. Weddings. Funerals. Barely remember or lost out - 82-91. But all the non medical friends welcomed me back sometime after the 2000s when I finally had time and energy to reconnect.

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Great article, Adam! During this process of acculturation (med school, residency, fellowship, early career) we necessarily force ourselves into a socioprofessional bubble, and we can be blind to our divergence from regular society. It's only later, when our social circles again expand (ostensibly through our children) that we may recognize the impact of our acculturation .

I think in many ways this contributes to physician burnout... Like rip van winkle, we "reenter" society oblivious to changes in society and life goals, different from when we entered (like your albums). I advise my own residents that negotiating this gap is crucial to long term professional satisfaction .

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author

So true. Thanks.

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Dec 10, 2022Liked by Adam Cifu, MD

Thank you for this essay, another absolutely accessible and illustrative insight into practicing medicine, wonderfully connecting all of us. I.e. with your writing, you are helping patients and medical health professionals not to be at odds with each other because when we each understand where the other is coming from the misunderstandings are prevented. But I admit that you gave my liver and spirit a great boost, with your paragraph about teaching 3rd years about diarrhea and your lecture title! As someone with chronic diseases and syndromes, many including that particular symptom as part of their presentations, I literally burst into hysterics, belly jiggling and all. Laughter from non ill-intended/mocking humor really is the best medicine (even when in our family's case the laughter induces wheezing in one of my teens and myself-so worth it). Again, thank you!

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author

Love it. Thanks so much.

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Dec 9, 2022Liked by Adam Cifu, MD

And this is why I have such reverence for doctors. I realize this piece is written to delve into acculturation, but to get there you had to go through..... And that is why doctors deserve more respect than they get. What I know about the entire process of becoming a doctor from the application to medical school through residency could fit on the head of a pin; but I know enough to realize the sacrifices and incorporation of humanism into a practice, to appreciate it. Doctors take all of those years of accumulating knowledge and then incorporate it into a chameleon who needs to change frequently to meet people where they are. Express information into a relatable language for that specific person/group. As for this writer having the patience to put up with my never ending list of questions so I can learn from you. Thank you Doctor

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author

Thanks so much Linda.

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Dec 9, 2022Liked by Adam Cifu, MD

Too bad you never finished House of God, one of my favorite books. I still have a copy. Have probably read it 3 times! (Gomers go to ground; don’t forget the roids). I was an ICU nurse in the late 70s and we were enmeshed in the training of residents and interns.

Always love reading your essays here😃

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author

I couldn't do it. It was the ICU nurses of the early '90s who saved me!

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"...For years, our field filtered out people based on their gender or skin color...."

Med school applicants are *currently* being filtered based on their gender and skin color. Respectfully, how are you not aware of this?

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Dec 9, 2022Liked by Adam Cifu, MD

Thank you Adam! "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." You captured that perfectly. And I have noticed the 1987-1996 knowledge gap often as well.

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Dec 9, 2022Liked by Adam Cifu, MD

“Currently, family income is a well-documented filter.”

Using the word filter here seems to imply that admissions criteria are actively, structurally biased toward applicants from richer families. So, we need to actively remove this filter. This framing can lead to proposals such as, “review medical school applicants holistically…” (a quote from the linked article), which clearly implies changing medical school admission criteria in service of a particular social equity goal.

What really needs to happen is for the root causes of social immobility and inequality to be understood---- and then addressed. The bottom line is that in the USA barriers to upward mobility via higher education are not primarily financial. A quote from The Human Network by Matthew O. Jackson: “ultimately the entrenched networks of information and norms that are shaped by homophily constrain opportunities and behaviors, and so it is these forces behind immobility that are primary— and one can view inequality as a result and not as the root cause.”

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Dec 9, 2022Liked by Adam Cifu, MD

The best tool we had of removing that filter while simultaneously advancing high aptitude individuals were the various aptitude tests. We are currently engaged in dismantling those, which will result in both a return to elite preferential admissions and arbitrary other nonaptitude admissions in their stead.

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Since part of this trend of mixing merit-based status with “disadvantaged” status involves race, there is also the risk, as Clarence Thomas says, that we “stamp minorities with a badge of inferiority.”

It’s not hard to imagine that once medical schools thoroughly succumb to this trend that people will start to choose their physician based on race.

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author

I agree. Filtering is often not active. I would not kids of means disadvantaged but also don't want equally deserving kids without means to not have a chance.

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Dec 9, 2022Liked by Adam Cifu, MD

Thoughtful post that resonated with me, esp. recalling own journey through acculturation in medical school and learning to bear the weight of responsibility in internship and residency. Melvin Connor’s book “Becoming a Doctor” dives into some of these issues from a sociologist’s perspective. Also thinking how dark side of “acculturation” can lead to medical groupthink and too ready acceptance of falsehoods promoted by medical “thought leaders” and trials published in “top journals”. Perhaps we should be reemphasizing critical independent thinking skills in medical training?

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author

Amen to that last point. I'll look for Connor's book, thanks for the recommendation.

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Dec 9, 2022Liked by Adam Cifu, MD

Your writings are so vivid and personal. I have savored them all. Regarding humor: can I say that my absolute favorite line from NeuroOnc during my husband’s glioblastoma journey came when we were all sweating on the conference call, waiting for the report after radiation treatments. NeuroOnc said, “It shrunk a crapload!” We all cracked up from relief as well as the phrasing.

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author

Thanks so much Beth. And thanks for making me laugh out loud this AM,

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We had that on the Chatter Blocks for a few months. Need I add that NeuroOnc was a somewhat brash New Yorker. We adored him

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Loved the coffee shop story in this piece. The little cheesy jokes and meaningless medical puns are my favorite form of medical humor. But sometimes because of what we see and experience, the dark humor you write about is a way of coping; the “I laugh instead of cry” phrase.

Thanks for sharing.

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Dec 9, 2022Liked by Adam Cifu, MD

thank you for this article. About humor, dark humor can not be understood if one does not have the knowledge and experience of its subject. "We can laugh at everything but not with anyone" is the quote of a French humorist Pierre Desproges. Also, medical black humor can only be perceived as really funny in this community (a consequence of acculturation). It's second-degree humor about absurdity and not everyone can understand it according to their culture. Also, my favorite humor remains self-derision, which cannot be blamed for the derision of other people. This is what you describe with your acute diarrhea teaching 😃 and maybe you will publish it one day.

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Thanks so much Kerrand. "We can laugh at everything but not with anyone" is priceless.

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So true 'we can laugh at everything but not with anyone'!! Ask any of us who have worked in the criminal system. Folks would not believe what we have found humorous, and we learn early on to keep our mouths shut about these things at dinner parties.

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Dec 9, 2022·edited Dec 9, 2022Liked by Adam Cifu, MD

I think that one aspect of acculturation which is almost universal in medical training is to believe that one's approach to disease, health, risk-taking and death are the norm, that is, normal. We should communicate from our own virtue-laden perspective and use our "objective" vocabulary. Sadly, this approach fails to appreciate how differently our patients see us, the healthcare system and disease itself. Nurses are generally exposed to education on health belief models which is cultural, spiritual and ethnic and is basically other-oriented. Physicians are generally under-educated in this regard but may learn during training through listening and learning.

I believe that health beliefs explain why African Americans remain so much more wedded to masking in public places than others. Their experience is that their ethnic group has had more disparity in outcome from COVID. Obituaries in my hometown newspaper consistently add in capitals the need for masking and COVID precautions at the future funerals of recently deceased African Americans. The prevalence of these precautions are even more striking than the propensity of masking in public which I witness almost every day.

Proper acculturation of physicians should include education on the variation in health beliefs. Good medical care is not just about making the right diagnosis and the right treatments but in connecting at a deep level with one's patients and listening to them.

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