The Year of the Intern

The Last Word

Dr. Peters has made the troubled journey from medical student through internship to the point at which society will recognize him as a full-fledged doctor. He can apply for, and undoubtedly receive, a license to practice medicine and surgery in any state of the Union. That will signal his readiness to be entrusted with all the responsibilities a medical license confers.

Thanks to his rigorous training, it can be assumed that he is ready academically. But is Dr. Peters equipped psychologically to practice medicine as a modern humane society has a right to expect?

"Old-line" doctors will be satisfied that he is. To the greater number of them, his personality aberrations are merely assurance that the "hazing" he got during his internship initiated him into the fraternity. Internship was rugged for them, and it should be just as rugged for the next generation. Toughen them up — these youngsters are too soft. Does such logic suggest that the older men may possibly be suffering from the same psychological problems as Dr. Peters, and for the same reasons? And what happens to the patient during these juvenile exercises?

The physician's traditional — indeed, antique — lofty standing on the world's scale of social values and, in the United States, the current awe of technological achievement have led to an attitude of increased veneration for the medical practitioner. As a direct corollary of this worship of all things medical, it has become unthinkable to question the medical profession's control over the education of the embryonic physician. Medical schools and medical training programs have been relatively free to do as they please. No one asks why.

Yet it has not always been so. The training of doctors in the United States was seriously challenged once, early in this century, when an extramedical group was appointed to study American medical education. This group — in the landmark Flexner report — mercilessly exposed the abominable conditions that then existed. Most medical schools, it said, were mere diploma mills totally lacking in academic controls. Indirectly, the report indicted the medical profession itself for having made such poor use of the carte-blanche charter given it by an adoring public.

This document had far-reaching effects. It began a gradual and relentless improvement in academic standards at medical schools. But its effects were not wholly beneficial. For one thing, the report made it possible for the medical profession — in the person of the American Medical Association — further to tighten its grip on medical education by actually decreasing the number of medical schools and training facilities — a move that was necessary, it was alleged, in order to raise the quality of instruction.

And the improvement and standardization of the curriculum that the report instigated caused the pendulum to swing toward the inclusion of more laboratory and science courses in the study of medicine. But the pendulum did not stop swinging until it had reached the point of infringing on clinical medicine. (Did anyone stop to think about the patient?) One result is that today's medical graduates are amply equipped with the latest hypotheses on the more bizarre diseases and rare metabolic processes, but they often do not know the simple clinical facts necessary to treat the common cold or how to deal humanely with a dying man who is beyond strictly medical help.

A feeling grows in America that another "Flexner report" may be needed to bring about reforms in medical training. There has never been an objective examination of the psychological education of physicians. Any mature, honest, and forward-looking analysis would have to consider it with the same seriousness given to academic excellence.

The public is distantly aware that some physicians are prone to personal peculiarities — the surgeon's childish tantrums, for example. Most people are more likely to be aware that when a student enters medical school his head is usually full of idealistic visions about relieving suffering, aiding the poor, and doing good for society. However, few have noted the discrepancy between the number of idealists who enter and the tiny percentage who come out on the other side with their ideals still intact. And hardly anyone makes the connection between lost ideals and the surgeon's silly antics. Or between lost ideals and the preoccupation of many emerging doctors, at the end of their long training, with "staking out a claim" to a financially and socially rewarding group of patients, and with buying luxury houses and cars to repay themselves for the deprivations of their years of preparation.

Obviously, the possibility that a doctor's ideals could change between medical school and medical practice is diametrically opposed to what people want to believe — and to what is presented to them in the mass media. Movies, television, and "doctor" novels have all tended to reinforce the myth of the inherent psychological health and goodness of doctors — especially young doctors.

Thus we return to the credibility of Dr. Peters as the representative of interns in general. Once more I state my belief that he is representative. He is not one of a few aberrant individuals. He is the typical young fledgling who began with relatively idealistic goals. He is the typical student and intern, whose personality gradually undergoes certain modifications that turn him into the whining, complaining, and selfish person we have come to know — understandable, but not admirable.

The contention that the medical world is full of Dr. Peterses is a large mouthful to swallow. If, in addition, it can be accepted that almost everyone who goes through medical school will suffer similar personality wounds, the suspicion might arise that the fault rests with the system, not the people entering it. And doesn't this, in turn, suggest that the system needs to be studied for its psychological effects, and altered toward a direction that would nourish, rather than extinguish, the idealism and sensitivity of its students?

Change is inevitable, and it is the hope of men and women of good will that change will be for the better — better for society and for each individual. Voluntary reform is a saner and healthier form of change than explosive measures taken as a result of abuse. It is time for analysis and reform in our medical schools and in the medical centers where interns and residents are trained if medicine — as both a science and an art — is to meet the needs of our time. Even the most thoughtful and probing analysis will be imperfect. Even the most earnestly pursued remedies will not be wholly successful. But if we cannot reach the ideal, we can move toward it. At the very least we will have had the sense and courage to try.