A young woman in a black suit and heels, with a leather portfolio hanging squarely at her side, stares at the wall across from the admissions office. She’s an applicant for medical school, on campus to interview with physicians, eat with first-year medical students, and tour the hospital with a docent in a pale-blue vest. At the moment, though, she’s contemplating a comic that hangs before her, a caricature of a doctor in a white coat. The doctor, who has devil horns and shark teeth, screams at a bewildered medical trainee then bites off her head.
Dozens of prospective students like this young woman show up in this hallway every week. It’s the most highly trafficked corridor at Pennsylvania State University’s College of Medicine, because the wall is covered with comics. On the way to the cafeteria, clinicians, staff, and medical students—current, yes, but especially aspiring—slow their hurried pace, intrigued by the unusual presence of speech balloons and cartoon images.
The wall tells the unofficial story of medical education—the lessons students learn outside of the formal medical curriculum. As the cartoon of the decapitated trainee makes clear, these lessons can be harsh.
The comics are created by fourth-year medical students in a course called “Graphic Storytelling and Medical Narratives,” an elective taught each spring by one of this article’s authors, Michael J. Green. In this course, students discuss medically themed, book-length “graphic narratives” and document their own stories from medical school in the form of short comics. Using comics is an increasingly popular tool in medical education. Known in academic circles as “graphic medicine,” the approach is part of the field of medical humanities, which emerged in the late 1960s to safeguard medicine’s personal touch. Medicine’s transition to scientific diagnostics and specialized treatments had jeopardized doctors’ intimate bonds with patients, so doctors needed to reinvent ways of connecting with people, medical humanists argued—a throwback to the mid-19th century, when doctors functioned mostly as missionaries to the bedside.
Today, American universities have four times as many undergraduate programs in medical humanities—known also as health humanities—as they did in 2000; many medical schools also incorporate some form of medical humanities into their official curriculum. Focusing on the doctor-patient relationship, courses explore topics like suffering and resilience, empathy, disability, and death and dying; the mediums include visual arts, literature, film, and “pathographies”—stories of illness written by patients or caregivers. Comics, a newcomer to the field, are an especially appealing way for people to tell their stories of illness. Recent scholarship has shown how reading these graphic pathographies can be helpful to patients as they navigate illness and the medical system, and also to medical students and practitioners as they seek to understand the impact of illness on patients beyond the walls of the hospital.
In recent years, medical students have also begun using comics to tell their own stories of medicine—from the other side of the stethoscope, so to speak, as they strive to make sense of what it takes to become a competent and compassionate physician. When given this chance to express themselves, they tend to illustrate the cognitive dissonance that can result when the lived experience of medical school contradicts its formal teaching. What emerges is not unique to this one U.S. medical school, but typical of the experiences of medical students around the world.
Indeed, throughout medical training, students learn many implicit lessons: what one needs to do in order to survive; how one gets ahead; how to interact with patients, teachers, and peers; where one fits into the broader medical culture and hierarchy; and what ideas and behaviors are considered acceptable. Collectively, these unwritten, unspoken, and unofficial lessons and rituals have come to be known by medical educators as the “hidden curriculum.”
What is this hidden curriculum? This question has no simple answer, but as the three of us—a physician, a literature professor, and an anthropologist—examined seven years’ worth of student comics, we identified five common, “unofficial” lessons from medical school. These lessons aren’t found in textbooks or formal lectures, but they are very much on the final exam toward becoming a physician.
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Medicine has a strict hierarchy and students are constantly reminded that they are at the bottom of it.
A core message of contemporary medical education, perhaps especially in medical-humanities courses, is that each patient should be treated with respect regardless of disease process, socioeconomic status, or belief system. Students find this message easy to understand, and most are able to practice it remarkably well, even with the most challenging patients. What often comes as a surprise, however, is the way they find themselves treated by members of their own profession.
Medical students are not individuals, but rather interchangeable generic units.
Through their comics, students reveal time and again an anxiety about losing their individuality during medical school. Most frequently, this is expressed in text bubbles where students are identified simply as “med student.” This demeaning appellation is delivered by diverse messengers, including not only surgeons, who are sometimes seen as brusque, but also pediatricians and obstetricians, who are generally assumed to be gentle.
Whereas outside medical culture the moniker “med student” typically conveys prestige, inside it can be used pejoratively, even as a means of minimizing or shaming a young, hopeful professional-in-training. Such generic labeling keeps students in their place, sometimes denying them any place.
Surviving medical school requires reading the mind of the attending physician.
Medical students often feel pressured to understand hospital rules and culture even when they exist sub rosa. Expectations can be unclear and conventions opaque. Sometimes, students feel like they’re expected to anticipate the future (“Move the camera where I am going to move!”) or read the minds of the attending physicians. One student expresses the impossibility of pleasing a doctor he calls Priapus (a Greek fertility god often depicted as a misshapen gnome-like figure with a giant phallus), who always manages to find a way to show his displeasure.
To get ahead, students should sacrifice their well-being.
Tending to patients’ health is the primary responsibility of a physician, but the system tacitly teaches—and reinforces in myriad ways—that tending to one’s own health is not a priority. This is especially ironic given the current nationwide push for wellness initiatives in medical schools. Savvy medical students understand that getting ahead means one must work most all the time, regardless of its toll on body and spirit.
Medicine is supposed to be patient-centered. In practice, it isn’t.
Another paradox students face is that while they’re told medicine is supposed to be about putting patients’ needs above everything else, in practice other considerations can get in the way. The comics reveal that students find themselves disappointed and frustrated with a system that makes it difficult for them to practice the lessons they’ve been taught. Even for the most compassionate students and doctors, the lack of time, piles of paperwork, and emphasis on rapid hospital discharge conspire against them. The students lament becoming participants and contributors to this process, yearning to maintain their ideals as they struggle with medicine’s realities.
Back in the hospital hallway, as that bright, aspiring medical student examines the comics before her, she likely dismisses the troubling aspects as humorous exaggeration. She likely thinks, “this will never happen to me.” But what images and word bubbles will she draw four years from now?