An Opinion on Early Medical School Learning
When my mom hears that I’m writing instead of studying anatomy, she tells me that I’m in school to be a doctor not a writer. She’s not technically wrong, being that I’m currently enrolled in medical school full-time and not working on a novel, but my retort is invariably, and often to her dismay, the same—playwright and physician Anton Chekhov managed to write during his medical studies in Moscow a hundred-twenty years ago, why can’t I today?
But after my small, semantic victory, I get to thinking about what she’s really trying to tell me. After all, I am studying to take care of patients one day, and the knowledge I’m learning now may in twenty years be the difference between a satisfied patient and malpractice lawsuit on my hands. So in everyone’s best interest, I should really just put down my pen and get back to the books, right? Right. But after aimlessly staring at the lecture for a bit (the slide I’m currently trying to avoid detailing the teratogenic effects of isotretinoin), I start to wonder, whose best interest is this really in, and for whom am really I memorizing this information?
I often look to literature for life advice (often times to my benefit, sometimes not so much), and Ivan Romanovich Chebutykin, an army doctor in Anton Chekhov’s famous play Three Sisters, stood out to me recently as an example of what not to aspire to. In my reading, he represents the end product of the Faustian bargain that is a modern medical education: a chilling example of a doctor who has sold every last remnant of his sense of self to his studies.
The Three Sisters invites the reader to join its myriad of characters in their mutual yearning for a time and place that has long since passed. The play, which opens on the anniversary of the three Prozorov sisters’ father’s death, revolves around the eponymous three sisters’ dream to return to the city of their upbringing, Moscow, and that dream’s never-ending undoing, heralded by a cast of disenchanted soldiers and Prozorovs engaged in endless squabble and conflict.
The army doctor, Ivan Romanovich Chebutykin, is introduced in act one as a longtime friend of the Prozorov family, and a loving man who wants nothing more than to praise the three Prozorov sisters, gifting them an extremely expensive silver Samovar. Later in the play, however, we learn of his propensity to drink, and in act three, Chebutykin drunkenly reveals his deepest insecurities about his profession:
“CHEBUTYKIN: [Glumly] They think I can treat anything just because I’m a doctor, but I know positively nothing at all. I’ve forgotten everything I used to know. I remember nothing, positively nothing [...] Perhaps I’m not a man at all, but I just imagine that I’ve got hands and feet and a head. Perhaps I don’t exist at all, and I only imagine that I’m walking about and eating and sleeping. [Weeps] Oh, if only I could simply stop existing!”
Chebutykin’s existentialist confession caught my attention for a couple of reasons. My twin brother studies physics, and he often jokes that medicine is not science, but phenomenology: while I don’t completely agree, and is obviously meant in jest, he does have a point—we as medical students memorize endless lists of drugs and genes not because we seek to understand their entire mechanisms of action (granted, we do know a lot of these), but because we are told that they work, and that should be enough. We know what drugs to give, when, or what symptoms to look for. We’re accepted to medical school not on the basis of our problem solving skills, as much as we’d like to think we are, but because of our uncanny ability to accept the information laid out before us like sponges. This is not in and of itself a problem. Medicine is the art of healing, and if treatment heals a patient, it should be employed, regardless of whether we fully understand its mechanism or not. The problem is, this type of pedagogy is not always conducive to a deeper understanding of the material, nor is it to its long-term storage. What a medical student knows for one test, he or she forgets for the very next. There’s simply just too much clinically relevant information to know all of at once. But what happens when we eventually lose all of it? Not the everyday knowledge that allows us to practice, but the minutiae we pore hours over, cramming on flashcards in order to conquer the battery of tests we must endure on a weekly basis. When we spend our time filling our heads with knowledge that’s not absolutely necessary for our future practice, nor useful for gaining a deeper understanding of the human body or medicine as a whole, it is setting us up for disaster. But we do it anyway, because we are told to and it will be tested.
It eventually goes, however, and it leaves nothing but empty space and wasted time behind. When our learning is not for us, nor for our future patients, we all end up like Chebutykin, knowing nothing at all and having studied it for no apparent reason. Chebutykin’s forgetting left a black hole behind, and it ate away at him from the inside— it robbed him of his life, and of infinite other passions and interests he could have filled it with. Instead, he becomes a shell of a person, perhaps not existing at all.
Historically, and certainly in Chebutykin’s case, our skill as physicians is tied intrinsically to our ability to recall our wealth of medical knowledge to treat patients. Medical students have had to in the past memorize this surplus of knowledge in order to function as successful residents and attendings. Nowadays, we have smartphones and computers to research information on the spot. As the technology we have at our disposal progresses exponentially ahead, and the information medical school exists to instill in its students becomes easier and more accessible to access, the necessity of our current system becomes less and less apparent.
Maybe as doctors we may look back at our medical education with fondness, and how we bonded over the rigor of classes and lectures that instill a sort of camaraderie between its victims. But is that camaraderie worth all of the pain? Is it worth any of it? Yet doctors that I speak to, even though they always admit most of what they learned in medical school is not at all clinically relevant, preach a similar brand of nostalgia towards their time there—it’s all part of the process, they say, you’ll undoubtedly learn to love it. But if I asked them to recall even a fraction of the muscles and cell-lines they memorized as students, I’m sure their answer wouldn’t be half as confident.
“CHEBUTYKIN: [drops the clock and breaks it] Smashed to smithereens! [A pause. Everyone looks upset and embarrassed.] [...]
IRENA: It was my mother’s clock.
CHEBUTYKIN: Well supposing it was. If it was your mother’s then it was your mother’s. Perhaps I didn’t smash it. Perhaps it only appears that I did. Perhaps it only appears to us that we exist, whereas in reality we don’t exist at all. I don’t know anything, no one knows anything.”
Perhaps all of us will forget everything in the end anyway, or perhaps we never knew anything in the first place. But this unknowing should not be treated ipso facto as an integral part of medical education—just because it’s expected that we will forget the information we’re taught, it doesn’t mean that we should have to spend our time blindly memorizing it in the first place.
Because when we make it our livelihood as students for four years to memorize facts we’ll seldom use, and when those facts inevitably fade away, it’s no wonder why residents are burning out long before they’re fully-fledged physicians: they’ve been led to believe that the more medical knowledge they cram into their heads, the more successful they will be. In the short term, this may be the case. They may ace their exams, get the best residencies, and impress the most people. But what’s left behind after they forget all of it is a vacuum; empty space that should’ve been filled with pursuits that bear fruit in the long term—building skills, following interests, and nurturing talents. Instead, all that wasted time collapses in on itself, leaving behind nothing but a deeply ingrained sense of dissatisfaction and disenfranchisement. The Three Sisters, and Chebutykin in particular, forced me to reflect on the time I’ve spent studying lately. Is it time spent bettering myself and my future patients? Or is it simply for my upcoming exam? Hopefully, I can make it more of the former. But like Chebutykin, when everything is said and done, I just hope that there’s something left of me to exist.