In popular culture, tales of the newly qualified physician abound. One of the most famous is that of A J Cronin’s The Citadel, in which a newly qualified Dr Andrew Manson battled ill-health and poverty in the Welsh valleys (Cronin, 1937). So influential was the novel that it was argued that it lay the foundation for the NHS in the UK (O’Mahony, 2012). More recently, popular fiction has taken doctors off their pedestal. In American fiction, Samuel Shem’s The House of God has become a required reading for any aspirant doctor. It tells of the brutalisation of an intern and his descent into callousness and near apathy before eventual salvation. The “Laws of The House of God” (Shem, 1978, p390) are often quoted at the induction of newly qualified doctor[1], some going so far as to say it is as if the medical “profession has exposed its unwritten rules into an unholy bible” (Boyes, 2004, p39).
In the UK, the fictional television series Cardiac Arrest, which played in the 1990s, has been described by doctors as the only show that “has ever come close to evoking the chaos and black humour of life in a British hospital” (Revill, 2006). The show charted the destruction of the idealism of a young new doctor, reduced to hoping an old man would have died in the ambulance before arrival to hospital so that he could steal a few hours of rest in the early hours of the morning (Cardiac Arrest, 1994).
The idea that medical practice will wrought dramatic change on a person is not confined to fictional accounts; in the first pages of the Oxford Handbook of Clinical Medicine[2] the authors write:
“We cannot prepare you for finding out that you do not much like the person you are becoming…House jobs are…the anvil on which we are beaten into a new and perhaps rather uncomfortable shape. Luckily not all of us are made of iron and steel so there is a fair chance that, in due course, we will spring back into something resembling our normal shape, and in doing so we may realise that it was our weaknesses, not our strengths which serves us best” (Longmore et al, 2007, p11).
For all the brutality a career in medicine is supposed to cause, there has been notably little said about the training given to those at medical school. Fictional accounts are limited to the, pleasing but shallow Francis Brett Young novels, or the more complex account of humanity given in Maugham’s masterpiece Of Human Bondage. Both authors wrote in the Edwardian period and painted accurate (autobiographical) pictures of medical training at the time. Yet the drama of medical school has never captured the public imagination, or entered popular culture in the same way that that hospital dramas have. We are supposed to accept that the destruction of idealism begins only when one becomes a doctor, forgetting that in most countries medical students spend the last three years on clinical attachment beforehand.
If Western medical training has barely been given due attention,[3] then it is little surprise that African medical education has been equally neglected. Claire Wendland, however, has begun bringing light to a seeming uncharted arena. Her book, A Heart for the Work, traces the path of medical students in Malawi and paints a contrasting picture with accounts of Western training.
Boys in White
One of the earliest studies of medical school was undertaken by four sociologists at Kansas Medical School in the 1950s (Becker et al, 1961). In the 1990s, psychiatrist Simon Sinclair looked at medical students in London’s UCL, as they progressed through their clinical studies and into their housejobs[4] (Sinclair, 1997). In both accounts, those that enter medicine are privileged; for Becker and his colleges this usually meant white Caucasians (Becker et al, 1961, p60). Writing sometime after, and in a far more cosmopolitan city, Sinclair’s student body is more diverse but he nevertheless finds them to be a “socially homogenous group” (Sinclair, 1997, p79)[5].
Medical students in Malawi, on the other hand, can come from a more varied background. Whist many are from privileged backgrounds, often having gone to Kamuzu Academy (known as the “Eton of the Bush” (Brind, 1999, 2007)), many were also clinical officers. These students had often completed some basic medical training and would have often spent several years being exposed to the realities of clinical medicine in Malawi. Despite their clinical experience, there is a snobbery between the students, with the clinical officers being from less privileged backgrounds than the other medical students. As such many of the faculty often express the view that the admission of clinical officers signifies “falling social and academic standards” (Wendland, 2010, p72).
In Malawi, as opposed to the West, medicine, for many students, is not so much a “choice than an inevitability” (Wendland, 2010, p73). There are a few master’s programmes and no doctoral training in the sciences. If a student shows any aptitude towards scientific work, only teaching and medicine appear as practical options. Teaching, with its poor working conditions and pay, is seen as an unattractive option and medicine is therefore seen as the natural resting place for those with an inclination toward scientific subjects.
Despite recognising the inevitability of medicine as a career, Wendland goes on to describe the quasi-religious reasons that students give for entering medical school. A pre-clinical student tells of how a stranger proclaimed from a vision that medicine was her destiny (Wendland, 2010, p74) whilst another tells Wendland of how he saw his “scholastic performance as revealing divine purpose” (Wendland, 2010, p74). Students felt that by becoming a doctor, they were doing their part in “healing Malawi” (Wendland, 2010, p81). Their entry into medicine was driven by nationalist impulses. Some had witnessed suffering of those they knew personally; others, like Mirriam Kamanga, talk of how delivering food to those affected by famine forced her to confront the suffering of ordinary Malawians:
“Reality hit and all, and I saw how much children suffered in Africa, Malawi in particular…. If I am a physician here, I hope and I pray that I make a difference to the suffering of children” (Wendland, 2010, p83).
Medicine, and the metaphor of healing bodies as a proxy for healing the country, is brought up repeatedly by the interviewees whom she speaks to. Whether these would be the reasons they give when students apply to medical schools, or whether these are thoughts they simply express to Wendland goes unsaid. We have no account of the admission process, and whether the motives of students are examined. In contrast, Sinclair was an active participant on an interview panel and talks of how candidates were generally advised against “demonstrating personal Idealism” (Sinclair,1997, p92), with candidates themselves recognising that replying “I want to help people” (Sinclair,1997, p92) is a cliché. Some ‘how to get into medicine guides’ go so far as to warn potential candidates that:
“Answers that will turn your interviewers’ stomachs and may lead to potential rejection are: ’I want to heal the sick’; ’I want to care for my fellow human beings’” (Sinclair, 1997, p87).
To the outsider it perhaps seems strange that British medical students are advised not to take an idealistic approach and that professing to want to heal the sick can be construed as negative. Yet such sentiments express a naiveté of what medical practice is, more so in Britain than the relatively resource poor setting of Malawi. Cynicism is admittedly seen as a national trait by many observers of the British (Mazella, 2007, p145), and Malawians may not hold self-mockery in such high regard. Nevertheless, whilst medicine undoubtedly makes a difference, the ability of an individual doctor to heal a nation is somewhat fanciful. Whilst British medical students are derided for even dreaming about saving their patients, Wendland lauds the Malawians for dreaming of saving their nation. Many of her respondents draw upon their evangelical faith as reason they become doctors, however Wendland’s superficial examination of the student’s motivation leave us only grasping at stereotypes of why they are drawn to medical school. Instead, we are left only with the notion that medicine is the new salvation, and that the medical students are the evangelical novitiates of this healing religion.
Admittedly, for Malawians medicine is a career not without its dangers. Wendland recounts how she was often told of clinicians who had died from HIV and other infections, caught from patients on the ward. Whilst not unknown in the developed world, the incidence is much lower (Wendland, 2010, p77); universal precautions are easily available as post-exposure prophylaxis medication. Such fatalistic working conditions no doubt grant a genuine edge to prostrations of wanting to heal.
In London, whilst medical students are occasionally given special prominence amongst other students, within the medical hierarchy they are firmly on the lowest rung. As Sinclair writes:
“New medical students are therefore in an unusual and ambiguous position: their friends and family at school are likely to consider them to be successful competitors for medical Status…but they actually find themselves on the very lowest Status in the hospital” (Sinclair, 1997, p1087).
In Malawi, where there is a great paucity of doctors, medical students are often elevated, especially when on their community placements. Even pre-clinical students who have yet to experience life on the medical wads find themselves cast into the role of doctor, as Joe Phoya recounts of his community placement:
“They tell you – us – ’As long as you are there, in the College of Medicine, you already are a doctor.’ So it’s that kind of feeling that sometimes make you already are a doctor.” (Wendland, 2010, p106)
From the day of their entrance to medical school, the mantle of doctor has to be assumed. As first year student, Mkuma Lifa, describes:
“Once you are at medical school, when you go home everybody says ‘You are a doctor’. If you don’t behave like one, you’ll feel you’ll disappoint them. So you just adopt the little things which make you – you do those little things which make you fit into the role that society has given you…You are supposed to be concerned primarily with people’s health rather than anything else. And sometimes when someone is in trouble, you’ve got to help.” (Wendland, 2010, p106)
Rather than the bar room frolics of the rugby club, or the hospital trolley racing down the main roads of the Rag teams[6] that Sinclair describes, Malawian medical students assume their role as healer from the moment they enter the medical school.
The Cutting Room
Becker and his colleagues devote several pages on work carried out in the anatomy labs. Here, students, working in groups, dissect a cadaver and learn gross anatomy from the structures they cut out. The dissecting room is an iconic cultural icon, one that separates medical students from the other ‘lay’ students on the campus[7]. It is the first time they will mutilate a patient, and hopefully the last time they will do so with no intent at therapeutic benefit. Writing in the 1950s, Alan Gregg describes his first encounter with the dissecting room cadavers:
“What most of us sought that first day among the naked, stark dead in the dissecting room was detachment – detachment enough to stand and view the machinery devoid of spirit, detachment and time enough to compose death with stinking life.” (Gregg, 1957, p25)
Dissection is often seen as the first step in the desensitisation process of the medical student. Desensitisation (or de-empathization as it is sometimes known) can at times be useful to “enable the physician to make sound, scientifically based medical decisions” (Lanadu, 2012, p108). One day, the doctor may have to do an unspeakable intervention on their patient; it can therefore be helpful to be able to disassociate between the person and the body.
Sinclair, too, notes that dissection marks an important stage in the lives of the medical students he studies:
“Because of its previous humanity, many students hold the body in respect; the link is made between their attitude towards the dead body and towards patients in future. This Idealistic attitude decreases as the body is dissected and its human integrity dismantled.” (Sinclair, 1997, p179)
Furthermore, for Sinclair the gift of the donated cadaver is highly symbolic. For some students he postulates that:
“…the exchange following the gift was that, after taking the gifted body apart in their training, they would spend their lives putting others back together again.” (Sinclair, 1997, p179)
If Wendland sees dissection as a fundamental stage in becoming a doctor, then it is all but absent from her ethnography. She writes only briefly, and almost dismissively of dissection; for her, ‘cadaver stories’[8] are to be only found in the West and would be unthinkable in Malawi (Wendland, 2010, p113). Yet, having to dissect and examine a dead body is so outside the realm of everyday experience that not to have a reaction to it would be strange. With the reaction left unsaid, one can’t help but wonder if the traumas of everyday Malawi surpass anything that can be seen in the dissecting room.
The Power of the Institution
The workload at medical school can be overwhelming. For Becker and his colleagues, several chapters are devoted to the volume of work that the students had to do and the pressure of examinations. Medical school can become an all-encompassing arena, and this institution starts changing the student. Medicine is an apprenticeship, and as Bourdieu writes:
“Between apprenticeship through simple familiarization, in which the apprentice insensibly and unconsciously acquires the principles of the ‘art’ and the art of living— including those which are not known to the producer of the practices or works imitated, and, at the other extreme, explicit and express transmission by precept and prescription, every society provides for structural exercises tending to transmit this or that form of practical mastery.” (Bourdieu, 2010, p88)
In plain language, students learn both explicitly what their teachers want them to know e.g. anatomy, and implicitly from observing their teachers e.g. how to behave in the hospital setting. Medical students can adapt the clinical terminology into everyday usage; both Becker and Sinclair note how members of the academic staff can be referred to as benign or malignant according to their temperament.
Becker recounts how the medical students start to describe the patients they need to clerk. “Crocks” (Becker, 1961, p317) are patients whose symptoms are largely (what we would now term) psychosomatic, and whilst students may feel sympathy towards them they tend not to be regarded as worthwhile patients:
“Prince decided that the patient was not really sick but just had a lot of trouble in his personal life that was making him sick. After the patient left he said ’I feel sorry for a guy like that. He’s really got a problem and there isn’t going to be much we can do for him…I don’t think he’s a goldbrick. I think he really does have pain and discomfort. It’s just not a kind we can deal with very well, I’m afraid”.’” (Becker, 1961, p317)
According to Wendland, for Malawian physicians, the social history is just as important as the clinical finding. That a mother had to walk thirty kilometres to find help was just as important as any clinical symptoms she may have (Wendland, 2010, p126). Whilst in modern medical training (certainly one which the author experienced) the social history is important, its status is relegated. Only in general practice or psychiatry would it be seen as essential, shielded from the world with their hi-tech biomedical facilities where most surgeons are happy to cut regardless of where the patient came from[9]. Admittedly, in Malawai even when there was an easily identifiable disease to treat, there may not be the equipment by which to treat them:
“On the wards there are no nurses. There is no equipment. There are no syringes. You come to work, you leave patients suffering because there is nothing you can use to help them.” (Wendland, 2012, p760)
Wendland does not shy away from retelling anecdotes of physicians that get nurses to position their stethoscopes on the chests of poor people so that they would be spared having to touch them (Wendland, 2010, p145). Similarly, the lack of medico-legal responsibility often meant that patients could be neglected, or no one held responsible for negligence (Wendland, 2010, p169). Corruption abounds, both at a national level (Wendland describes how a minister subverted a programme of sending heart patients abroad to instead send their own relatives) and at the level of the medical school (where we are told of how a group of students find one of their teachers publishing their work as his own). Yet despite working in the face of such hardship, Wendland argues that the adversity, in fact, allows the Malawian students and doctors to remain politicised. Drawing on the writings of the philosopher, Martha Nussbaum who states:
“Knowing can be violent, given the truths that are there to be known.” (Nussbaum, 2001, p45)
For Wendland, medical practice in the West depoliticises suffering (Wendland, 2012, p757) and there is truth in what she says[10]. Wendland takes the argument further, however, for her practising medicine in Malawi caused a political radicalisation (Wendland, 2010, p202). The:
“…doctors responsibility for diagnosis and treatment are exercised in relation not (solely) to the individual patient’s body but rather in relation to the collective patient, the body politic.” (Wendand, 2010, p203)
More than medicine, doctors felt they could give their patients hope (Wendland, 2012, p767) and students frequently spoke of “love, heart, passion or spirit” (Wendland, 2012, p177) when describing their work. Wendland recalls how she herself described on of her colleagues as being “an asshole …[though] a really good doc” (Wendland, 2010, p178) and how such a statement would be a contradiction in Malawi. This, for Wendland, is ultimately her central argument (and where the title of the book comes from). For her, being a doctor in Malawi requires heart (Wendland, 2010, p178) and she refers to the term uMunthu[11] or the collective sense of humanness (Wendland, 2010, p180) as being a key characteristic in many of the doctors she meets.
Why this difference between Malawian students and ones in the West? Wendland explores whether it is because of the evangelical Christianity that many practiced or whether some notion of Africanness could be used to explain it. Ultimately she decides that whilst:
“In my clinical practice in the United States, even in an underfunded clinic among very poor patients, there was always some medication to give, some test to order, some surgical procedure to try, some referral to make. This was simply not true in Malawi. In response the new doctors expanded the definition of wat they could give that was important, and empathy and love took pride of place.” (Wendland, 2010, p179)
Her Malawian medical students attend medical school and whilst learning the clinical knowledge, master also one of the most important qualities of being a doctor, that of empathy. Instead of theoretical discussions and communication skills workshops where empathy is taught to western medical students, Wendland’s Malawian medical students seem to master it unknowingly. As Bourdieu writes:
“The explanation agents may provide of their own practice, thanks to a quasi-theoretical reflection on their practice, conceals, even from their own eyes, the true nature of their practical mastery, i.e. that it is learned ignorance (docta ignorantia), a mode of practical knowledge not comprising knowledge of its own principles.” (Bourdieu, 2010, p19)
Yet, such visions of the African medical student becoming politicised and gaining an accidental mastery of empathy can also come across as highly romanticised. Writing in response to Wendland, the Dutch anthropologist, Sjaak van der Geest, postulates that the politicisations and criticisms of the state are how the doctors maintain their self-esteem (regardless of how justified the criticisms are). Furthermore, he compares the development of empathy to Scott’s concept of ‘weapons of the weak’ – not so much a different medical attitude but an attempt to maintain their dignity (van der Geest, 2012).
Conclusion
Medical school can be an all-encompassing place. Even if there are no physical walls preventing interaction with the outside world, the volume of work is enough to keep its students confined to its libraries and clinics[12]. They are, what Ervine Goffman would describe as, a total institution:
“Every institution captures something of the time and interest of its members and provides something of a world for them; in brief, every institution has encompassing tendencies. When we review the different institutions in our Western society we find a class of them which seems to be encompassing to a degree discontinuously greater than the ones next in line. Their encompassing or total character is symbolized by the barrier to social intercourse with the outside.” (Goffman, 1961, p3)
The anthropology of medical students has not been as well studied as other aspects of medical practice. In regards to medical schools of the developing world, Wendland has shone light on an area of almost complete darkness. For that reason alone, The Heart of the Matter is worth reading. We gain a glimpse of medicine in Malawi and what medical school must be like. When compared to the Western ethnographies, Malawian medical students come across as almost morally superior. But therein lies the weakness of Wendland’s work. The medical school as a ‘total institution’ is not explored. Whilst Sinclair and Becker et al spend considerable time detailing the intricacies of the medical school, Wendland seems to gloss over it. Her methodology may account for some of the difference; in contrast to the other works, she does not systematically follow a group of students through their lectures and clinical work but takes a more scattered approach, basing her work mainly on interviews and focus groups. Rather than try and immerse herself in the institution of the medical school, she instead holds on to her outsider identity of senior physician and anthropologist. Instead of a critical ethnography we find ourselves reading a partially romanticised hagiography.
[1] Whilst some of these laws border on callousness e.g. “If you don’t take a temperature you can’t find a fever” (Shem, 1978, p391); others, whist appearing whimsical are later realised as pearls of wisdom e.g. “At a cardiac arrest the first procedure is to take your own pulse” (Shem, 1978, p391) as attested to by this author’s own experience.
[2] Due to its distinct appearance, the book is sometimes known as ‘the cheese and onion’ in reference to the traditional colours of the Walkers crisp packets. Others simply come to know it as ‘the Bible’ as junior doctors (the author included) have to rely on it as the source of all wisdom and guidance when they first start.
[3] With some notable exceptions, which we will discuss during the course of this article.
[4] Traditionally after qualifying, first year doctors would take the position of house surgeon/physician in a hospital. As these jobs were previously residential, they became known as housejobs.
[5] Along with these two luminious works, the author of this article will (in a small way) bring in his experiences of medical training between 2006-2010 in the East End of London. When the text of this paper refers to ‘author’ it is to mean only the author of the paper, and not the illustrious authors of the ethnographies discussed.
[6] Rag week is where British university students collect money for charitable causes; within the medical school this often involves dressing up in scrubs and collecting on the tube trains with all manner of clinical props.
[7] At the author’s university, the dissecting room was located squarely in the centre of campus; entrance was granted only by electronic key card access to medical students who spent the rest of the time off campus in the medical school adjacent to the hospital.
[8] ‘Cadaver Stories’ refer to the black humour employed by medical students when faced with their cadaver; they may make reference to cannibalism or necrophilia. Whilst some do so out of sheer insensitiveness, others may do so as a way of coping.
[9] This, admittedly, is a personal reflection of the author’s decade long experience of medical practice.
[10] From the author’s own experience of working with a deprived population, there have been times when social ills are treated with medical means; patients with lack of housing or access to benefits are prescribed anti-depressants rather than the correct social remedy.
[11] Here, she references the Chichewa saying: “a person is a person through persons” (Wendland, 2010, p180).
[12] Authors personal experience, which would be unfailingly confirmed by many of his contemporaries
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