The Blight of Third Year

My third year of medical school has been an exercise in restraint.  I am consistently disappointed by the terrible descriptors used to discuss patients.  Smelly, stupid, ignorant, etc., are all words I have heard used to define patients.  This mostly comes from the residents and is often defended by the fact that they are working long hours in difficult conditions with little sleep.  But to me this is no excuse.   

It is no surprise then that students exposed to this behavior are destined to repeat it.  This has been called the “hidden curriculum” of medical school.  Far from the shining examples of patient care gone right is a world of loathing and dissatisfaction.  Doctors find themselves pulled away from family, bothered by seemingly meaningless problems, and thrust into a world where costs matter but cannot be contained. They then let loose their resentments in the only direction they can: at patients.   

Perhaps this is why the third year of medical school, the first clinical year, is where cynicism takes root (Hojat, Vergare, Maxwell, et al., 2009; Newton, Barber , Clardy, et al, 2008).  We have created a cycle of discontent.  Students flock to the wards, after years of cramming book knowledge, only to have their fantasies quickly quelled by those ahead of them.  Instead of learning the finer points of end of life care, I have found myself in surgeries that the surgeons jokingly called “autopsies,” since the patient might has well have been dead (and likely would be soon). Rather than being part of a teachable moment, I have seen patients given unnecessary antibiotics to satisfy their “complaining.”  And I have seen patients who, for cultural reasons, denied care and were called ignorant, missing the opportunity to explore a culture not our own.

Many have attempted to explain this slow erosion of compassion.  Reasons abound, from the introduction of electronic health records, which diminishes direct patient contact, to the push for evidence-based medicine, making algorithmic and science-oriented medicine predominate over individualized care. But as a third year student the causation is obvious – poor role modeling.

Imagine if the above scenarios had gone differently.  What if the residents had voiced concern over operating on a dying patient who was unlikely to get benefit from the intervention?  What if the attending listened?  That would have been a dramatically inspirational moment, one that would have greatly impacted me as a student.  A lot of money is being spent on learning how we can improve student empathy and patient-centeredness.  Perhaps the solution is a sizable bolus of compassion.

Third years are so impressionable as they flood the wards in their short white coats, scurrying after attendings like baby ducks after their mother.  They are easily influenced because they are searching for a way to fit in and impress.  We do not need another lecture or activity to guard students from the fate of bitterness. We need instructors to step up at each opportunity, to share teachable moments, and to perhaps ask themselves, “what would I want my doctor to do?”  One day it might be them, laying on the gurney, benefiting from those wonderful lessons in compassion.


Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-91.

Newton BW, Barber L, Clardy J, Cleveland E, O'sullivan P. Is there hardening of the heart during medical school?. Acad Med. 2008;83(3):244-9.


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The progression of science is comprised of tens of thousands of scientists and ancillary staff simultaneously adding cogs to the gears of the machine that is science. A few of those scientists are forever well-known for adding entirely new gears upon which new cogs will form. Those are the “famous” scientists. But lest we forget those that have dedicated their lives to adding the cogs, no gears of a machine can function without the cogs upon which they rely.
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