I was told this by a patient once. I guess they thought this would be a revelation for me. Cute.
I made it a mission to indoctrinate upcoming medical students with this and various other rules which I called “The Truths of Medicine”. I hope that one day this will be obsolete. Or canonized.
“But that’s a pretty cynical view of physicians, isn’t it? We aren’t cowards!”
Keep telling yourself that.
“But why are doctors cowards?”
Think about what it takes to become a physician. Think of the mindset that is required, the time that it demands, and the amount of delayed gratification it takes (some would say a life time…). You spend two or more decades in schooling (grade school through medical school). Your life is nothing more than jumping through academic hoops, checking boxes, and performing activities that ultimately have little bearing on what you will do later in life. It all seems arbitrary but there is a reason to the madness. It is conditioning.
In order to make a “good” physician, you have to think about what it would take to make a good slave. You have to keep their focus narrow. You have to overwhelm them with activities that ultimately have no greater purpose than to test their ability to complete a task. You have to teach them that there is no other way. You have to make it difficult, if not impossible, for them to be able to break out of their servitude. But most importantly, you have to make them believe that their current position is noble and that to desire anything different is sinful or selfish. The last one is essential.
Focus Them In
Medical school is an extremely specialized training, however the specialization is gradual. The first two years of school is a broad overview of human anatomy, physiology, disease processes, and pharmacological interventions. To say that the information you are exposed to can be overwhelming is an understatement; it is impossible to absorb and retain it all. You aren’t supposed to. You are supposed to figure out what you want to start forgetting. And then Adderall. Or Ativan. However you cope best. But once you make it out of the first two years, mentally ravaged, vitamin D deficient, estranged from friends and family, and properly conditioned to believe that this is normal and necessary, you are allowed to progress to Stage 2.
Stage 2, also known as your third and fourth year, is about finishing the conditioning and narrowing the focus. Where you previously had some control over when you got to sleep, eat, shit, and breathe, those privileges are immediately lost the second you walk into your clinical rotations. You are told where to be, at which time, and how long you will stay there by various people who are not your parents or law enforcement. You really have no option but to be there, at least most of the time, lest you fall into their bad graces and risk failing (read: doing it all over again). In addition to being trained how to follow arbitrary orders, you are exposed to even more specialized fields for several weeks at a time in order to figure out what field of medicine you will accept having your life scheduled around. All that information which was shoved down your throat during your first two years begins to be pared down to fit the confines of your respective area of interest. It is by getting to “choose” your area of interest that provides you an illusion of control. Even slaves need to feel empowered sometimes. But this choice is just a means to further focus you in and prepare you for the next stage of conditioning known as residency.
Do everything. Expect nothing.
The endless onslaught of inane activities is not something unique to medical school or the post-training-mind-fuck known as residency. For those pursuing the lofty goal of being labeled a physician, these activities seem nearly life long and start early. From the extra credit and consistent completion of homework, to the time spent in extracurricular activities and volunteer work to prove that you are “well rounded” (read: fit to jump various hoops), it seems your entire life is an amalgamation of experiences which were collected for the sole purpose of being granted that golden ticket into medical school; your entire life is nothing but a means to an unsatisfying end. And it is not like the requirement for continued “activities” stops upon admission into medical school. No, that would be too humane. In addition to being waterboarded with information, you are “encouraged” to continue doing volunteer work, join committees, perform research, and make every effort to remove the idea of “free time” from your vocabulary. Of course, you are free to go against Master’s recommendations however you risk not advancing to the next level and being stuck with hundreds of thousands of dollars of debt; your incentive is a carrot-flavored stick. You are in too deep. Better get to ladling out that soup.
But you get through it. Somehow. You may not have the clearest memory of it and may have even exaggerated a few things, but it is done. Your fourth year is here. You can breathe. Well, you can breathe after you collect your letters of recommendation, write your personal statement, write about what makes you unique (protip: there is nothing that makes you unique but the system demands obedience), go through your specialty-specific fourth year clinical rotations, spend thousands of dollars on additional 8-9 hour multiple choice exams, applying to residencies, and traveling for interviews to various residencies, and then submitting a match list while waiting in eager anticipation for 3-4 months to figure out where you will be contractually obligated to spend at least one year of your life. Easy. In comparison to the other three years, it is better. It provides the student (read: slave) with a relative reprieve before they jump head first into their life long struggle with alcoholism and drug abuse (read: career). Even slaves need a Sunday.
But then residency starts and you begin to see what your training was truly about: conditioning. Where most people would whine, kick, and scream over the prospect of waking up between 3-4AM for 26 days out of a month, working 12-36 hours straight, being verbally and occasionally physically abused by “customers”, explaining complicated medical conditions and medications to middle-aged children with a third grade reading level, being blamed for everything that happens by anyone that is considered above you (this includes patients), working with various bosses (read: attendings) with widely inconsistent personalities and preferences, all while trying to attend lectures, submit research proposals, and finish all your work for an ever increasing patient census before your shift ends in order to not go over your arbitrarily determined “duty hours”, we simply call it another Tuesday. We are so conditioned at this point that we cannot imagine anything else. This is our normal. This is our reward.
As was already alluded to earlier, even if you can see through the smoke and mirrors and know the game for what it is, you cannot escape. Or at least, you cannot escape unscathed. Many people complain of college loans and difficulties paying them off when they graduate from their four year alcohol bender into an entry level barista position at their local Starbucks. I get it. You were lied to the moment someone allowed you to sign up for a major in political science. But to put it in perspective, one year of medical school tuition is about the equivalent of four years of in-state college tuition. And if you went out of state for a four year bender without a (real) science or math degree, you have no one to blame but your parents.
But getting back to the cost of conditioning, medical school costs on average about $39K a year if you are in-state and close to $60K a year if you are out of state. Unlike college, where going out of state simply means you want mom and dad to be farther away, most people do not have that option to be selective about which state they will be conditioned in; you go where you are accepted. So, to do some basic math for the Poly-Sci majors, you are looking at $160-240K for four years of conditioning and this does NOT include the cost of living, exam fees, or travel expenses. The only thing that seems more expensive, and produces about the same results, is Scientology. Furthermore, nearly everyone passes their first year or they are made to repeat it. The only time that dismissal from the conditioning program becomes necessary is in the event that you fail (multiple times) the first of many day-long exams called Step 1. This is taken in your second year. At best, you are already $80-120K invested and quitting is only an option if your parents are wealthy. For the rest of us plebs, failure or escape is not an option; we are riding this train to its final destination and it’s a long trip.
This is what you deserve
“the understanding and encouragement of altruistic behaviour is vital in maintaining the public’s respect for the medical profession, and altruism is also a key dimension of a doctor’s work that helps prevent demoralization and burnout” – Jones. BMJ 2002.
This last part, as I had mentioned before, is the most vital part of maintaining the slave mentality among those that have completed a life time of conditioning. Altruism seems to be the default moralistic stance taken by those involved in the medical field. It is viewed as an ideal morality that helps promote selfless actions by all in health care for the benefit of the patient; it is the only acceptable morality. But just like everything else, it is simply another tool for control. It is for controlling your soul.
You can cage an animal. You can make it perform a routine. You can make it proficient at that routine. However, if the animal still desires more, or desires out, you still run the risk of being mauled to death once a limit is reached. How do you stop this? Well, when it comes to man, you teach them either to not desire anything or that their desires are disgusting, guilt-inducing, or harmful. That is altruism.
Altruism is a slave morality that has been used for centuries to control populations. It is an extremely effective tool. It teaches that if you are not selfless then you are selfish. And if you are selfish then you are exploiting those around you and depriving them of their needs. Therefore, in order for you not to steal or deprive someone of their needs, you must be selfless and work for no other task but to provide for the well-being of others. Your needs are irrelevant. You are irrelevant. You must work. This is a great way to stave off demoralization and burnout.
Jones is right that altruism is a “key dimension” of a doctor’s work. Without it, doctors would not be able to continue with their tireless effort of taking on more and more responsibilities and burdens without seeing any additional reward. Slogging through the never-ending changes in health care regulations, queries from documentation specialists, requests for “Peer to Peer” discussions over payment denials by insurance companies, CMEs, MOCs, decreasing compensations, and increased patient work load takes a special degree of self-neglect, cowardice, and guilt to maintain. Thankfully, physicians have been well-conditioned to the point that many may even feel overcompensated when they actually start to earn a real paycheck. There can be no better proof of the slave mentality of physicians than to see one marvel and occasionally question their new income upon transitioning out of residency. “I don’t feel like I deserve this much…”. You’re right. But not in the way you think.
“Then how do we change it?”
You don’t. You can only change yourself. But maybe if enough “selves” are changed the system will take notice. And then try to destroy you. Because the system does not want to change. The system is working just fine for the system. The only way out is to break the system; to take the red pill and wake up. You must demand more. Fight more. You must get angry. You must be willing to lose everything in order to gain back your humanity.
But doctors are cowards.