As a medical student with a mere 18 days left of my third year—the alleged “darkest year of medical school”—I feel compelled to comment on this well-written piece from Danielle Ofri MD. If you don’t have the time to read the whole article, this gif gives a pretty good summary.

By and large, I agree with what Ofri has written here. I have seen the transition in my classmates, some more than others. I have personally felt a lot of the emotions she describes. A year ago, I was chomping at the bit to see patients, but just the other day I found it difficult to get excited for a full day in the clinic. What is responsible for this transition?

Ofri provides a comprehensive explanation of the major contributors and does well with her explanations. Here, I’d like to focus on what I think are the major contributors:

- The “hidden curriculum” teaches all

In her 9th paragraph, Ofri points the finger at the implicit lessons taught to medical students through the modeling provided by their attendings and residents. It is through this implicit teaching where students begin to learn the acceptability of loathing certain patients—the drug-seeking patient in her 5th ED this week, the smoker with advanced COPD who won’t quit, or the obese patient with diabetes and degenerative joint disease but still unable to lose weight. She writes (in very careful, polite prose):

The students astutely note how their superiors comport themselves, how they interact with patients, how they treat other staff members. The students are keen observers of how their supervisors dress—and how they may dress down those around them. They figure out which groups of patients can be the object of sarcasm or humor, and which cannot.

Though most attendings or residents are excellent role models, many are not and openly display disdain for patients, insurance companies, hospital administrators, pharmaceutical companies, governmental agencies, other physicians, nurses, other health care professionals, or—at a minimum—lawyers. The lesson learned—it is ok to disdain or disparage these groups and it is ok to do so openly in contexts where you are the senior person. The larger problem is that such behavior can be insidious. It leads to a place where the “other” is always blamed and the “self” becomes infallible. No longer do you loathe only the drug-seeking patient, but all patients in pain and in need a relief. Unfortunately, the “hidden curriculum” is very efficient at socializing students into a culture they never would consciously participate in.

- The practice of medicine is difficult work

Ofri acknowledges the difficult nature of clinical medicine at several points. She does an excellent job of describing how the difficulty of the work is compounded for med students new to the wards. We are constantly in new places, learning new workflows and staff dynamics, not to mention the actual medicine we are supposed to be mastering. One thing I’d like to bring out—and a subject that Jay Parkinson MD MPH wrote about so eloquently a week ago—is the fact that many days in medicine are taken up by horrible, horrible things. Parkinson writes:

The one thing about being a doctor I just couldn’t handle is you are the point person for all the horrible things that happen in society. An NYU student jumps from the 10th floor of the library, you see it. In fact, I saw three of those one year. A kid in the projects a few blocks away tries to scale down from the roof of the building to enter his burned down apartment to get his video games, only to have his rope break from the 12th story, you see that too. You see the kid who was riding his skateboard on the sidewalk as his neighbor is mowing the yard who inadvertently runs over a baseball sending it into the child’s head at 300mph, yep, you see that too…The one thing I could never get used to was simply how often babies are born in toilets and left to be found by someone else only to be rushed to the ER and transported to our Neonatal Intensive Care Unit. Their first breath in this beautiful world is toilet water. This happens more than any of you could possibly think and I would care to remember. 

Seeing such things is, to put it mildly, stressful. And then there are the hours. I spent three full months working 12+ hour days six days a week (and I know I have many more long months ahead in my training). I have classmates who worked longer hours. It is hard to not become a little jaded in this context.

- All is not lost

Given what Ofri wrote and I have discussed here, are we doomed to producing emotionless and jaded young physicians? Absolutely not. Robert Centor MD provides an excellent perspective on Ofri’s piece and the role the third year of medical school plays in the training of physicians. Centor alludes to the fact that though we have difficult times in our training, we are also afforded the privilege of experiencing miraculous times with patients (something I touched on recently). 

I have found my third year of medical school instrumental in my medical education. After some dark and trying months, I now know that I have the capacity to deal with long hours and difficult, tragic situations. I feel prepared to take on the challenges residency holds for me. My classmates and I need that confidence going forward in our medical training. Could we make the third year better? Probably. But sooner or later in our training we have to face some of the difficult realities of practicing medicine and demonstrate our commitment to our patients.