Introduction

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The Socialization of Doctors: The Hidden Curriculum of Medical School

Timothy B. McCall, M.D.

Many of the cornerstones of a doctor’s philosophy of practice are formed in medical school. At the start of medical school, most students are in their early 20s and impressionable, their beliefs and worldviews not yet fully formed. Most are idealistic. They want to help people and serve their communities. Contrary to popular belief, few students choose a career in medicine because they want to make big money. If that were their primarily goal, it would be far more efficient to go to law school or get an MBA, where after two or three years, they could land a high-paying job. To become a doctor requires four years of medical school after college, and, depending on the specialty, three to seven years of additional training. While their contemporaries in law and business have long since begun to reap the rewards of their professions, young doctors are often putting in 80 hour weeks and living modestly. Meanwhile, their debts from medical school, these days often topping $100,000, accrue interest.

Whatever idealistic goals medical students start out with, most are profoundly changed by the time they finish their training. Much of this is due to the strong socialization pressure they experience. Besides the official curriculum of medical school—the study of anatomy and various diseases— there is an unofficial curriculum of biases and attitudes inculcated into students every bit as methodically. The following is a partial list:

• Attitudes about specialists. One reason why we have a surplus of specialists in this country, is that almost all professors in medical school are specialists and they convey the message that the best doctors are specialists and the more specialized the better. Good students are taught not to lower themselves by choosing a career in primary care. Several professors and one of the deans of my medical school went out of their way to try to dissuade a classmate of mine from going into family practice. It worked. She ended up choosing a surgical specialty.
• Attitudes about technology. When it comes to diagnosis and treatment, students learn that newer and higher-tech is better. Death is the enemy and must be defeated at all costs—it is almost never better to let a patient die in peace if doing so denies that patient the opportunity of a longer life, regardless of the quality of that longer life. Students learn to disdain the “soft sciences” like psychology. The role of emotions and social conditions in medical problems, if not openly disdained, is largely ignored.
• Attitudes about alternative medicine. In medical school, students are taught contempt for everything alternative, dismissing it as unscientific, based only on anecdotal evidence. Professors routinely make disparaging remarks during hospital rounds and in lectures about alternative practitioners, such as chiropractors and acupuncturists. There’s a real double standard applied to alternative medicine. If a chiropractor misses a diagnosis or injures a patient, it’s held up as proof that chiropractic is quackery. If an M.D. misses a diagnosis or injures a patient, that doctor may be criticized (in private) or the situation may be considered bad luck but it’s never held up as an indictment of the field.
• Attitudes about malpractice. A virtual paranoia about getting sued by patients is instilled in young doctors. Horror stories, such as the case of a woman supposedly awarded a million dollars after she claimed an X-ray of her head caused her to lose her psychic powers, are repeated ad nauseam. Students learn that “greedy lawyers” are responsible for the “malpractice crisis.” Never is any mention given to the possibility that doctors practicing low-quality medicine might contribute to the problem. Young doctors are taught to never criticize another doctor in front of a patient, no matter how flagrant the mistake, for to do so would only invite a malpractice suit against the other doctor.
• Attitudes about prevention. By watching their professors in action, students “see” that treatment is more important than prevention. It’s not that anyone says, explicitly, that prevention is a waste of time. It’s just that very little attention is paid to it. Students learn almost nothing about vital subjects like nutrition. Professors in fields like public health or preventive medicine are generally held in lower esteem than cardiologists or neurosurgeons.

Not all students swallow the hidden curriculum without critical analysis but too many do. Think of the average doctor’s attitude toward alternative healers. Students who at the beginning of their training are open minded have no opportunity to investigate fields like acupuncture, because their time is monopolized. Saddled with heavy debt, most young doctors then go directly into full-time or more than full-time practice. Few ever take the time later on to explore alternative medicine but their general suspicion toward it lingers.

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