I Don’t Think That Thought Process Means What You Think It Means*

One day on rounds (the time when physicians, residents, and students discuss the day’s plan for each patient they’re caring for) I commented on a patient’s amazing carpenter veins (colloquial term for veins on the back of the forearm which tend to be prominent in people who work with their hands). Having once put in IVs for a living, it’s hard to shake my deep appreciation for a good vein when I see one. The physician leading the team and a resident both stopped and asked, “What do you know about carpenters?” They asked this as if I couldn’t possibly know anything about people who are carpenters. It was a joking question which is common in medicine when calling out someone’s knowledge gap.

I was completely dumbstruck by their assertion that I couldn’t have interacted with many carpenters in my life. After a long pause, I mumbled something about having put in IVs as part of my work before medical school where I had many carpenter patients with these veins. I was confused because sometimes I forgot that many people assume all med students have no experience outside of university classrooms and have doctor parents, or at least white-collar parents. If I had been less taken aback, I would have told them I know a lot about carpenters in a happy, matter-of-fact tone.

My father is a carpenter. My stepfather and mother don’t call themselves carpenters but they both do a lot of carpentry as part of their regular lives and as part of their work. I, myself, have helped build houses, furniture, and theater sets. In fact, one of the more memorable childhood photos of me depicts an elementary-aged me hammering a bolt into some floor beams. In double fact, my first work was in carpentry helping my parents build our house and working on paid building projects. Which is to say, short of being a carpenter, I feel confident calling myself an expert in what the life of a carpenter is like (without even mentioning all the carpenters I’ve cared for as patients since I started working in healthcare as an EMT years before medical school).

As humans we make many assumptions because it helps us organize the world – for better or for worse. Physicians are trained to come to quick conclusions and identify disease patterns almost as quickly as their patients decide if they like their new doctor or not. This is why your doctor will often only ask four questions before they decide how to investigate your knee pain – their experience has taught them how best to understand medical situations and make a strategy for those situations in a 15-minute appointment. Obviously, there are many medical situations where more than 4 questions are needed, but I say this as an example of how physicians are trained to make even more assumptions than the average person already does.

Often, the assumptions physicians make about medical symptoms are helpful because they lead to quick recognition of life-threatening medical conditions so they can be addressed in time to save someone’s life or allow the physician to develop a reasonable method for exploring the situation further in the confines of an overburdened, short-for-time system like the US medical system. But, as we all hopefully know, assumptions are dangerous when they come to making conclusions about whole persons. Note the difference between assumptions about symptoms versus about people. It’s assumptions about people that lead to biases.

It’s assumptions that play a role in the dark side of healthcare – like black people having their pain undertreated or receiving inferior medical treatment and transpeople receiving poor medical care (Google these if you want to know more, there’s plenty of data. There are also numerous other examples of disparities in health stemming from biases and assumptions about people).

Now, the assumption that I, a medical student, hadn’t interacted with carpenters before was erroneous on the part of my supervising physician and resident, but it doesn’t compare to disparities in care secondary to biases and assumptions. I brought those up in the previous paragraph to illustrate some of the ways assumptions infiltrate medicine beyond what I experienced and beyond their helpfulness in identifying diseases quickly.

What my situation does show is that the mental picture that many people in the US (including physicians themselves) have of who US doctors are is a bit out-of-date. There was a time when almost all doctors were white men, and many were from doctor families. And, today, the percentage of white male physicians is still greater than the percentage of white males in the population. And, separate category, there are still many medical students who have doctor parents or white-collar parents. Yet, while this is true, it is also true that things have changed a lot in medicine.

Today, there are more women than men enrolled in US medical schools. There is also a growing contingency of doctors and medical students who aren’t Caucasian (check out this article). There is also a growing percentage of medical students who will be the first doctors in their families (check out this article and this data)

There was a time when most physicians became physicians without ever leaving school – they’d pass from high school to college to medical school to residency. Today, the average age of people starting medical school is 24, which means that they took 1-2 years off from school somewhere along the pipeline. And that’s the average, meaning a significant portion of people starting medical school are older than 24; people like me, I was 29.

All this is to say that who medical students are now is different from what most of our older patients and seasoned physicians have seen most of their lives. For example, as the carpenter story suggests, my teaching physicians thought I was naiver than I am and had a different background than I do. As a different example, as a female medical student my older patients (mostly the men) think I’m a nurse. I find this particularly ironic and amusing because my husband is a nurse; he has no interest in being a doctor and he is a far better nurse than I ever would or could be given my nature.

Looking at the modern world of medicine and the medical world we want for our future, it’s time to check our assumptions about medical students and reevaluate who they are because their backgrounds may surprise you. And to disclose one of my biases, I think the diversifying of the physician force is awesome and, perhaps more doomsday, the only way we’ll solve many of the medical profession’s problems.

*Attempted The Princess Bride reference, not sorry because Inigo Montoya summarizes my thoughts more often than I would like to admit