1) How does a young man or woman like me get inducted into the culture of medicine?

2) What are the social processes that will transform me (a medical student) into a counselor and intervener in issues of life and death ie. a medical doctor?

3) How will undertaking contact with the most private aspects of human life change me as a person?

Many students enter medical school with idealistic views of medicine and its goals, and become more realistic and cynical as they move through the training process. Your medical education places pressures on you to adopt values and views that are consistent with dominant medical beliefs and practices. The process of learning about medicine directs and limits your diffuse sense of moral concern. What students learn is to clarify and define their obligations and responsibilities to patients and others. This process is analogous to other forms of learning in medicine – you begin with imprecise ideas and gradually modify them in the face of experience."

The American College of Physicians states that ‘it is unethical for a physician not to report fraud, professional misconduct, incompetence or abandonment of a patient by another physician.’ It also states, however, that is ‘is unethical for a physician to disparage the professional competence, knowledge, qualifications, or services of another physician to a patient or a third party or to state or imply that a patient has been poorly managed or mistreated by a colleague, without substantial evidence.’ This second statement is more a statement of professional etiquette. Certainly, it is better to keep speaking out within the usual channels where possible, but it may be necessary to go outside them."

The doctor-patient relationship is one of the strongest therapeutic tools a physician has. The fundamental elements of the ideal physician patient relationship can be expressed as six "Cs": Choice; Competence; Communication; Compassion; Continuity and No Conflict of Interest

The patients should have a choice of finding a doctor with whom they have rapport. Patients expect their physicians to be competent; this entails four elements of: a good fund of knowledge, good technical skills, good clinical judgement and the willingness to consult other physicians as required by the situation. An ideal physician-patient relationship requires good communication. This requires an understanding of the patient’s symptoms, values, and the effects of the disease on the patient’s life, family, job and other pursuits, as well as the ability to explain to patients, in clear and comprehensive language, alternatives available in diagnostic and therapeutic treatment and how these alternatives are likely to fulfil or undermine the patient’s values. The patients may not only need technically proficient physicians, they also want doctor who have compassion. There is a need for a continuity of the doctor-patient relationship. This is particularly important for patients’ who have chronic medical conditions. Finally, a physician’s care of a patient and concern for the patient’s well being must take precedence over the physicians’ own personal interests especially financial interests.

Dr Soin also said that the doctor needs to take the middle path where clinical medicine combines the biomedical and non-biomedical aspects. This path has been succinctly stated by Dr Walsh McDermott:

‘The physician seeks to do 2 main things: To manage biomedical knowledge of practical use – its technology – in an effective and discriminating fashion for the prevention and management of illness and disease, and to establish peace of mind.’ With regard to the latter point, McDermott continued as follows: ‘Medicine itself is deeply rooted in a number of sciences, but it is also deeply rooted in the samaritan tradition. The science and samaritanism are both directed toward the same goal of tempering the harshness of illness and disease. Medicine is thus not a science but a learned profession that attempts to blend affairs of the spirit and the cold objectivity of science… These 2 functions, the technological and the samaritan, are separable in the world of analysis but not in the world of real life… A doctor cannot get a passing grade by being proficient at one or the other; he must be good at both, for they are to be regarded as opposite sides of the coin.’

"Walsh McDermott emphasized the primary importance of bio medical science as a basis for medicine but his view also expresses his clear understanding of the fact that medicine is more than biomedical science."

Dr Soin concluded, "To sum up, medicine is a broad discipline, a helping profession, which has a constantly growing body of knowledge to call upon.

1. The Social Medicine Reader edited by Gail E Henderson, Nancy M P King, Ronald P Strauss, Sue E Estroff and Larry R Churchill.

2. Student BMJ April 1977.