Medicine and books: Making Doctors: An Institutional Apprenticeship
Authors: Simon Wessely
Journal: BMJ (1998)

Simon Sinclair 

Berg, £14.99, pp 347 

ISBN 1 85973 955 5 

Read this book. It is written by a qualified doctor who interrupted his career to study anthropology and undertook his field work by returning to medical school to observe the habits and dispositions of those who study and work there. It is in turn fascinating, nostalgic, and, ultimately, depressing. 

Simon Sinclair has produced a masterful account of rites of passage, a study of initiation in which the raw recruits enter medical school and progress through its various nooks and crannies to exit as members of the tribe some five years later. During that time they acquire knowledge (a little), take part in rituals (several), and acquire attitudes (a lot). This is called medical education. 

Sinclair observes the formal ways in which students are taught—what he calls the official, front stage activities of the ward round and lecture theatre—but he devotes equal time to the backstage activities of the dissecting room and the unofficial activities of the student show and the action in the bar that follows. Sinclair sees medical education as a theatrical experience, whether the formal rituals of the ward round or the raucous rituals of the Christmas show. 

For Sinclair, the show went off the rails in the Victorian era, with the transition from the patient as client, in which medical care was dispensed at home, to the patient as case, an inhabitant of the hospital and property of the consultant. The bedside gave way to the ward round, and the hospital consultant assumed the dominant role in medical education which he (it is usually he) retains. 

It is Sinclair’s analysis of hospital hierarchies that is so particularly dispiriting. There are the good and bad patients. Bad patients are those whose ambiguous status, neither well nor ill, most reflects the students’ own ambiguous position. The most reviled are the crock, the fat folder, the somatiser, and the overdoser, who seem to be ill but possess none of the tickets of admission, such as an abnormal radiograph, physical sign, or laboratory test. Psychiatric patients, who can never give a “good history” and who may, through their unpredictable behaviour, embarrass the student in a ward round or exam, are equally loathed, as, by transference, are those who look after them. 

The psychiatrist is thus the lowest form of medical life, but is joined in the first circle of medical student hell by psychologists, sociologists, and general practitioners. In Sinclair’s jargon, they lack proper Knowledge (“hard facts”), do not give proper Experience (finding physical signs or learning practical procedures), and do not have proper Responsibility (going on as they do about multidisciplinary teams). All medicine is multidisciplinary—how many people contribute to the case of a patient undergoing cardiac surgery?—but it is only psychiatrists and general practitioners who actually acknowledge this fact. The student, desperate to acquire the duties and privileges of the tribe, views those who carelessly give away that status with contempt. 

As a psychiatrist, with a soft spot for the tradition of medical anthropology exemplified by this book, I found reading Making Doctors increasingly stripped away my delusions about the popularity of our teaching. We encourage students to question simple dogmas and combine this with what we believe to be trendy, holistic, patient centred approaches, like our colleagues in general practice. It cuts little ice with Sinclair’s University College students—a particular blow since I used to consider students at UCL to be the most socially aware in London. However, I consoled myself that at least our insistence on empirical research, backed up by convincing statistical evidence, would restore our reputation. It was thus a shock to read that “statistics is above all the subject most disliked by students,” since it lacks everything that students respect—no hard Knowledge, no Status, and no Responsibility. Is it too late to start surgical training?