Integration

This above all: To thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man.—Shakespeare. Hamlet. Act 1, Scene 3.

“This is a ‘panel’ of two?” I ask, horrified. In preparation for my contribution to “Expectations of Third-Year Medical Students,” I had briefly jotted down notes between a hostile pager, a long wait for a crowded elevator, and while paying for my ridiculously expensive sandwich from the hospital cafeteria. Know how to give a seven-minute presentation that is really seven minutes. Know the most about the patient. Learn how to call a consult. I have some general thoughts to contribute, but not enough information to keep an hour-long session going for a ward-ready group of soon-to-be clinical clerks. My fellow panel-mate is a pediatric resident. I am the attending. It is just us.

I quickly scan the room of faces seated in the lecture hall. These are not the poker faces of my peers in their white coats, pretending to pay attention in Grand Rounds. Not even the faces of our seasoned MS3s with their air of self-assurance as they quietly slip out of rounds to return a page. These students are in their civilian clothes, wearing jewelry, with hip hairstyles, makeup even. They have not yet experienced sleepless nights, nor been tainted by the hidden curriculum. They anticipate with pleasure the idea of a pager going off, because it will mean they are needed by a patient or a nurse. Even the pharmacy texting them, in all caps, that they omitted the medication route will be exciting, as it will be evidence that they are finally empowered to write orders.

I briefly allow my thoughts to wander back to the day I sat in this same lecture hall. I remember what it felt like to be in their shoes—or do I? Seven years has taught me a new language, given me new blinders, and colored my world in subtle ways. I remind myself that the students probably want nuts and bolts—what to wear on the first day, what to keep in the pockets of their white coats, what books they should be reading.

I start by introducing myself, warming up. “I was a student here not so long ago,” I tell them. “I remember standing in your shoes, feeling the nerves, the excitement. Starting third year is a big change from the first two years. To be anxious about it is normal. So let's start by hearing some of the questions you have. Go ahead,” I encourage, adding naively, “ask me anything.”

In the front row, a young brunette woman with long bangs lifts her arm with bangle bracelets clanging. “How do you stay true to yourself and not do things asked of you that aren't right?” “Good question,” I respond, inwardly cringing. “Let's take another.”

A dark-haired crew-cut man in a university sweatshirt in the back right corner: “Should we expect to modulate our personality to better fit the people we work with?” “Another good one,” I respond, beginning to panic. Where are the easy questions? Who wants to know if they can wear open-toed shoes on the wards? Where to wear their stethoscopes?

From the middle. A quiet-looking blonde woman, hiding behind her stylish glasses: “How do you advocate for what you believe is best for your patient, but still be respectful to the members of the medical team?” Hands continue to rise. My heart is thumping, my ears rushing. I can't hear the questions. The enormity of my underestimation of this audience sinks in.

As a teacher of these students, I am supposed to have answers. I was confident entering that this would be an easy noon hour. I would impart my savvy, and they would enjoy the session. But I am struck by the gravity of the questions they are asking. How did these clinically naive students anticipate the real-life moral conflicts they will experience as medicine clerks? Their questions, these ethical dilemmas—they are real and they are important. They are also infinitely more difficult to answer than to explain a q5, q3 short call system. As their teacher, respecting the thoughtfulness of their questions, I reply what I hope is an equally thoughtful and honest answer. I don't know.

I think of the times when I observe inappropriate behavior and say nothing. Of the times I feel that I am acting as a physician, hiding under my white coat, feeling nervous that someone's father might die or that I am missing a wife's diagnosis. I struggle each day to advocate for my patients, always feeling as though I should do more. The issues raised by the students have a common theme: Integrity. How does one maintain integrity as a physician?

Integrity is defined not only as “adherence to moral and ethical principles” but also “the state of being whole, entire, undiminished.” I prefer the latter definition. From the same root comes the word integration. As students of medicine we will always be attempting to integrate, not only our knowledge and clinical skill, but literally ourselves—into a new team, a new hospital, a new system. In this imperfect training experience, each of us will feel our own way, trying to balance our integrity. Some will mold themselves to be exactly what is desired of them, others will be judged for being too outspoken, too eager, too contrary. We will hurt for our patients and we will beat ourselves up for not doing enough, for protecting ourselves, for compromising our principles for the sake of grades, sleep, a personal life. As I gaze at their expectant faces, I begin to see that my role is not to provide set answers, but rather to help guide them to find their own. I try to give them a framework, a place to start. I acknowledge that the root of these questions is the very essence of physicianship, our daily struggles with courage, humility, and advocacy.

Despite the pressures of the clinical experiences and our desire to integrate ourselves to the culture of medicine, the team, the hospital, at the end of the day, we all have to live with ourselves. Not the attending who made us cry, the patient who yelled at us, the nurse who shamed us. These hard questions asked cannot, will not, be answered by our teachers or mentors. The answers will not be the same for all of us. We must be kind with one another, be respectful, and, above all, be true to ourselves. The ability to remain whole through this indoctrination: this is a challenge to every medical student, every physician. My students don't need to know the answers to their questions today. They just have to know that they are the right questions, and they need to have the courage to live them.