Boys in White; Student Culture in Medical School.
by Howard S. Becker, Blanche Geer, Everett C. Hughes and Anselm L. Strauss.
University of Chicago Press. 456 pp. $10.00.
Boys in White is an exceptionally interesting sociological study of the highest technical quality. The authors have undertaken to study medical education as medical students actually experience it, rather than in terms of its stated objectives or official curriculum—though their book includes a lucid and detailed descriptive summary of the medical course as background for discussing what happens to students in pursuing it. But as the authors put it in their introductory chapter:
The administrators and the teachers of our chosen school and of other medical schools may not find full expression given their own hopes and plans for students. Instead, they may find what appears to them over-emphasis on the points where their work has not been fully successful, where—in spite of their best efforts—things have gone awry. We remind those teachers that throughout the book we are saying, “This is how things look and feel down under. This is how, whether anyone intends it or not, it is for the students.”
In order to do this, the research staff became “participant observers” of every phase of training offered in the University of Kansas Medical School. They went everywhere with the students, even on rounds and into the operating theater. While their status as sociologists who were not going to become doctors was made very clear, the students seem to have accepted them as peers; they occasionally discussed plans for cheating with the research team and in one case insisted to a member: “Go ahead. Get up there and feel those [enlarged lymph] nodes. How are you going to know what happens to us unless you go through the same experiences?”
Since they are studying medical school from the viewpoint of sociology, the authors start with the hypothesis that the most significant actions and attitudes of students would be expressions of their collective situation rather than of their individual values and immediate feelings:
In short, while students of industrial behavior and even the managers of industry have accepted the fact that levels of effort are determined by social interaction and are, in some measure, collective phenomena, both the social scientists and those who teach candidates for professions have tended to see the problem of effort and achievement in the professional school as a matter of individual quality and motivation. We have been reluctant to apply to professional education the insights, concepts and methods developed in the study of lowlier kinds of work. This is but another instance of the highbrow fallacy in the study of human behavior; what we discover among people of less prestige, we hesitate to apply to those of higher.
Nevertheless, we did bring to our study of medical students the idea that their conduct, whatever it might be, would be a product of their interaction with each other when faced with day-today problems of medical school.
This is really the central point of the whole book and amply borne out by the authors’ findings. Their hypothesis is empirically verified. Yet, it seems to me that they are not quite aseptic about it. Despite their continued insistence on the value of disciplined empiricism as the chief source of merit in research, this finding escapes from the empirical structure of the study and becomes an article of ideology as well as a finding. This, after all, the authors finally imply, is the way things are and have to be, and it is irrational to expect or demand that young men under pressure ignore the demands of their immediate situation and be guided by their preconceived values—if only because these values will not have been defined specifically enough to tell the students what to do with them in school. Even the occasional boy who remains convinced that medical insight is more important than passing examinations is almost certain to be defeated by the problem of finding out what medical insight is in practice, and how it may be developed in the course of dissecting an obscure cadaver or doing workups on clinic patients who have nothing left to lose but their hypochondria. He gives in and becomes an empiricist in the immediate situation because his earlier values turn out to be irrelevant to it.
As a useful and original device for organizing their findings on what is relevant, the authors use George Herbert Mead’s concept of group perspectives, and examine how these change as the situation of the medical student group itself develops through the course of training. Most students begin the freshman year with an initial determination to “learn it all”; swiftly discover that they can’t, and, with more or less reluctance, adopt the perspective of trying to learn “what the faculty wants us to know”; i.e., what will be asked on examinations. They can then afford to be intolerant:
I talked to Shep Boas after psychiatry conference. He was very tense. He said, “I don’t like this kind of thing at all. I don’t like these conferences where people [students] ask questions. I can’t think of anything to say. And besides I think it really wastes your time; even in class I don’t like it when they [instructors] ask questions because we are here to learn and take it from them. . . . It is up to them to give it to us. It is not something to be argued about.
Earlier, the authors had commented:
Thus, in changing . . . to the criterion of “what the faculty wants,” a student does not give up his independence [sic]. If he gives up the demand that he be taught what he will later use and asks instead that he be examined on what is in the book, he acquires a powerful defensive weapon against the faculty that has the advantage of being close at hand.
Later, in the clinical years, the perspective shifts because the situation changes. But the clinical perspectives are as empirical as those of the freshman year; they are merely applied to a different problem situation. Here the emphasis shifts to the “medical responsibility” and “clinical experience” perspectives, though concern about “what the faculty wants” continues even more pervasively as a concern about making a good impression in the face-to-face contacts that now occur, replacing anxiety about grades as such. As the authors use the terms, the “medical responsibility” perspective refers to the student’s constant concern that, as low man in the school hierarchy, he seldom gets a chance to do anything that will affect a patient’s chances of recovery significantly. “Clinical experience” refers to the students’ comparable conviction that the use made of students in the teaching hospital greatly limits their contact with any great variety of interesting pathology. These are the terms in which they judge patients; what they dislike most are “crocks” with nothing concrete the matter with them; you can’t learn anything from them.
These perspectives are entirely short-run. Paradoxically, while many of the students resent the greater responsibility and opportunity for first-hand clinical experience available to interns and residents, they show no real confidence that they will receive similar opportunities when they become interns or residents themselves. They are concerned with their immediate educational experience, and what is missed now is gone forever. The authors accept—I think it would be fair to say they defend—the students’ pragmatism as a healthy form of realism: they are not doctors yet, and it is appropriate rather than callous for them to judge patients largely as learning material. But callousness is not the real issue so much as the students’ practice of ignoring, from their student perspectives, the equally empirical long-range human consequences of whole situations. They are practical-minded:
Frequently students simply speak approvingly or otherwise of a department, teacher, or particular teaching activity on the ground that these did or did not provide “information” or “pearls.” These are both shorthand terms for the kind of material the lecturer in the preceding example (referred to as “really very practical”) was praised for providing—“information” is the generic term, “pearls” are particularly valuable single pieces of information.
As might be expected, the students tend to find psychiatry so traumatic that it is probably fortunate that they only encounter it in the presence of a psychiatrist. An observer reports of a student:
The psychiatrist does not respond to the overt meaning of what the student says. Instead, he responds to what he thinks is the underlying meaning. . . . The student, on the other hand, wants to get through the hour as painlessly, with as little embarrassment, as possible. To do this he wants to do anything within reason that he knows how to do that will satisfy the psychiatrist. But he tends to think in concrete and immediate terms, the way he thinks about physcial disease, and this simply does not mesh with the way the psychiatrist does business. For example, the student wants to put things into classifications and so he . . . wants to classify his patients as paranoid or schizophrenic or whatnot. The psychiatrist keeps telling him to get away from these and use his understanding on the individual case. The student might be willing . . . if he knew how, but he doesn’t.
Nowhere in their training do the students show signs that they are beginning to realize that whole individuals become ill, in the course of complex lives. They seem unable to respond to this kind of wholeness, even when the subject is themselves. The authors believe that the choices of medical specialty made by students—with the exception of those who set out from the beginning to be psychiatrists or surgeons—are “essentially playful”—“an experimental trying-on of roles about which they know very little”; and no statistically significant differences between the numbers of would-be specialists and general practitioners develop through the four years of medical school. Whatever else medical school teaches these students, it does not teach them to approach life situations as complex problems that are interrelated; though nothing could be more essentially empirical than this.
I do not believe I have distorted the authors’ conclusions, though I have certainly-selected for discussion those that seem to me most important to the non-medical reader. But the tone of this review would give a very distorted picture of the tone of the book, which combines investigative rigor and tolerant optimism. In their final chapters the authors stress their conclusion that the students never lose their idealism; they merely adapt realistically to the situations they must face if they are to get an M.D. so that they will have a chance to use it as physicians.
Students retain an idealistic view of medicine even though they re-orient it in the direction of greater realism and adaptation to the immediate situation and to the medical practice they envision for themselves. The perspectives they develop while they are in school and those with which they leave school for internship and medical practice may be characterized as being pragmatically idealistic but not in the vague and nonspecific way that characterized them as freshmen. Rather, they have come face to face with the realities of medical school and have gained, in addition, a much clearer picture of the realities of medical practice. . . . They transform their naive idealism into a set of perspectives designed to deal with the specific problems they encounter and expect to encounter.
Just so. Francis Powers could do no more. The authors quote many excerpts from students who are finishing up in medical school that express a commendable degree of dedication to the welfare of the community and of the individual patient. But, as before, these seem to be the views the students express between decisions, not in the process of making them.