I am thinking about how much the people you are around influence the way you think and talk. Yesterday morning, the attending, Dr. K, was a maternal-fetal medicine specialist. He is in charge of morning report once a week, as well as being the attending in the clinic whenever they have high-risk clinic (pregnancies complicated by diabetes, twins, isoimmunization, hepatitis C, etc). The second-year resident, Dr. T, was reporting on a patient she had admitted the previous day. It was the woman’s fifth pregnancy, and she had presented with placenta previa (implanted over the cervix, thus very prone to disastrous hemorrhage) and bleeding which was now controlled. Dr. T went on a little length about the woman’s history of depression and asthma, exacerbated by her poor social circumstances. Finally Dr. K waved his hand impatiently and said, “There’s something very important about this patient which you did not include in your history. What is it?” Dr. T guessed; the amount of the bleeding? that it was the first bleeding episode? that they had verified the placenta previa on the hospital ultrasound? Dr. K demanded, “She has four children; how were they born?” Dr. T allowed that the last two had been born by Csection. Then Dr. K wanted to know what this put her at risk for. Dr. T was at a loss for words, so I started whispering, “placenta accreta” (where the placenta implants into the muscle of the uterus, not just the covering epithelium as it ought to; this causes even more severe hemorrhage, sometimes only controllable by emergency hysterectomy; the risk for placenta accreta increases with the number of pregnancies, with past Csections, and with placenta previa). This turned Dr. K’s attention to me, and he started quizzing me about the exact numbers: risk for placenta accreta with just previa; with one past Csection; with two Csections. I had no idea, and guessed randomly, about 10% off every time. It turns out that this woman’s risk for placenta accreta is 40%. This changed the plan drastically; Dr. T had been ready to send her home, since it was her first bleed, and was stopped now. But to let somebody with almost a fifty-fity chance of placenta accreta go home, an hour away from the hospital, when her next bleed may require massive surgery to save her life, is not possible.

So during this interrogation I felt sorry for Dr. T, to be embarassed like that, with no help or hints from Dr. K or anyone else; but I also thought it was very bad for a second-year resident, in charge of managing difficult pregnancies, not to think about placenta accreta in this case. It didn’t hurt me to be quizzed, because I was close to the right answer, and no one expects medical students to know much about OB. From my previous interaction with Dr. K, I thought he was a very good specialist, and fairly decent to the residents, letting an intern do a whole private Csection of his, and joking with her and other residents.

Then, later in the morning, two of the other students started discussing how cruel they thought Dr. K’s questioning had been, and how unreasonable, and that they thought from previous episodes that Dr. K has a special animosity for this particular resident. Listening to their opinion, and their accounts of the past, I began to think that perhaps it was unkind of me to approve so much of Dr. K’s behavior, and that it was inappropriate for me to disapprove of Dr. T spending so much time on the relatively unimportant depression and asthma.

Downstairs in clinic two of the nurses began discussing Dr. K, and their bad opinion of him. They think he is rude and overbearing to them and the residents. Now, one of them did base this on his not responding to her sexual innuendo. But the other nurse, who is more decent, agreed with her judgment. So I started off the day thinking well of this doctor and respecting him; now, based on the criticism of other students and nurses, I begin to think very poorly of him. To what extent should I let myself be influenced by the opinions of other people – some of whom I don’t respect at all?

At the beginning of this year, for all my two years in medical school, I still looked at medicine and doctors relatively from the outside. It was still a new and mysterious species and culture. Now, without really seeing a specific turning point, I realize that I am inside; I accept things as normal because the doctors I’ve worked with for the last year think they’re normal. And our normalization sets the stage for patients to accept our statements and directions without much questioning (especially the class of patients we work with; not so much the private patients). I think I can still see when a doctor uses technical language, and the patient doesn’t understand a bit; but I don’t know how much longer I’ll have that. I’m now used to the shorthand and Latin that we use “inside,” and I forget how much even the junior medical students don’t understand.

Yesterday the front page story in the newspaper was about a local “AIDS doctor,” who is also just incidentally the co-founder of the local gay and lesbian medical association (along with Dr. C of family medicine infamy, the one with the transgender patients). He lost his license for alcohol and drug abuse (both prescription, and ecstasy). Some of the students were discussing this, with a chief resident sitting in the corner doing paperwork. One of the girls remarked that the doctor had explained his behavior by saying he worked in a very stressful field. Although they had been saying all kinds of questionable things about the case, at this point the chief resident interjected firmly that lots of doctors work in more stressful fields, eg oncology, and that is no excuse at all for drug use. The chief knew that we can’t allow ourselves to make the slightest excuse for this behavior, since we are all so close to it to start with. Personally, I’m sorry for that doctor being on the front page of the paper; but I can’t help feeling it’s poetic justice for a gay activist to end up like that.

My own behavior is changing. After working with a couple of students who dither a little bit, and take extra time to make decisions, I’m becoming very decisive and controlling. I feel like their slowness hurts the performance of all the medical students. When we’re together, I don’t wait for those two to discuss anything; I tell them, do this, and rush off to do the part I assigned myself. Now when I get home I’m starting to order people around the same way; and my family doesn’t appreciate it.

Last piece of socialization occurring this week: One morning I was in charge of making sure all the babies to be circumcised arrived in the correct room, and that all their paperwork was filled out. It turned out later that one of the babies, although his mother did want him circumcised, belonged to a private doctor, not to us, and thus we had no business circumcising him. I blame myself, for not realizing that his last name didn’t belong on our list. The nurses got blamed, because they’re the first ones in the chain to say, the residents need to circumcise this baby this morning. But the intern who did the actual procedure blames herself the most. After I apologized a couple of times for getting her in trouble, she stopped me by saying, “It doesn’t matter what you or the nurses did; it’s my fault. I am the physician, and I am ultimately responsible for everything that happens.” I’m coming to admire this intern a lot. She doesn’t grouse as much as a lot of interns do; she’s always cheerful with patients, and takes time to listen to their depression and social issues (even if she doesn’t report it all to the attending). When she has time for students she’s a good teacher. I am impressed by her strong sense of responsibility, even after being a doctor for only seven months. (And any legal characters out there, don’t get interested; the private doctor didn’t mind, and we got the mother to sign a consent for the intern; so it’s all honest and orderly now.)