A Journey of Initiation

In Medical School

By Melvin Konner, M.D.

Elisabeth Sifton/Viking. 390 pp. $19.95

AS AN anthropologist, Melvin Konner lived in the African bush to record the lives of the primitive !Kung San tribe. At the age of 33 he left a successful academic career to satisfy an unfulfilled wish to become a doctor, leaving one closed society for another. In Becoming a Doctor, he reports on what the passage into that most elite of American professions is about, not by describing the four years he spent at Harvard Medical School (in the book disguised, for no given reason, as "Flexner School of Medicine") but by focusing on what he considers to be its most formative stage, the third year, when young men and women who since their freshman years in college have been mastering a steadily accelerating mass of knowledge about biochemistry, endocrinology and anatomy are first exposed to the hospital world of patients, procedures and death.

In the tradition of participant-observers, Konner experiences the culture he has entered, adopts some of its mores and rituals and then steps back and tries to interpret what he has seen. In doing this he succeeds in offering some insight into the mythology of medicine and the process by which a special few are initiated into its mysteries and the rest of us are not only excluded, but in some ways, Konner suggests, turned into the enemy.

That there is a "crisis" in the training of physicians in this country has become accepted both within and without the profession, and its causes have been hashed over by everyone from the American Medical Association to the deans of some of the nation's most respected medical schools. Konner is not optimistic that anything will change soon. In fact, he dismisses much of the profession's rhetoric about the need for more "humanistic" education as "pieties." As he describes the process by which student attitudes are passed from one generation to the next, it's not hard to understand his pessimism.

Much of Konner's narrative about his experiences as he is initiated into different specialties during his third-year rotations will seem like well-traveled territory to anyone familiar with the number of reports from the front lines of medical education that have appeared in recent years. Tales of inhuman hours, cutthroat competition, neurotic classmates, insensitivity to patients and youthful arrogance have become familiar, and the hospital slang of "turfing" patients, "gorks" and "L.O.L. in N.A.D." (for little old lady in no apparent distress) are well known to readers of Samuel Shem's wonderful book about an internship, The House of God, or anyone who has watched Dr. Craig on St. Elsewhere.

In the hospital world that Konner describes, nurses are wise and unappreciated, surgeons are arrogant, pediatricians sensitive and the interns and residents with whom he spends most of his time nearly finished with the process of socialization by which they have learned to distance themselves from those they treat -- the process, as Konner puts it, by which people become "patients." Konner brings no special writing ability to describing this process. And he is frustratingly reticent about his own motivations, both in deciding to leave a successful academic career for medicine and, after he finishes medical school, deciding to return to teaching without doing a residency.

"Clinical medicine," he writes, "is one of the experiences -- like falling in love, or parenthood, or (I am told) war -- the appeal of which is difficult to appreciate from the outside." But as Konner describes it, the appeal is quite simple. In an ambiguous and bureaucratic world, where it is not always clear that what one does for a living has any impact beyond the next desk, there is nothing as clear cut, as inarguable, as alleviating pain or saving a life. What clearer sense of purpose can exist than that, especially if to achieve that purpose involves a considerable amount of personal sacrifice along the way? Konner argues that it is precisely because of those sacrifices, made by medical students and young doctors in the course of their long and grueling education, that we feel comfortable in granting doctors their incredible power. After all, he says, they have suffered to earn that position and the lofty place, in money and prestige, that society assigns them once their training is complete.

Konner recounts the story of a friend who had a patient so grateful for having survived a life-threatening illness that he kissed the student's hand. The student was thrilled, and then suddenly disgusted that he had taken such pleasure at what he saw as the illegitimacy of his power. He left clinical medicine to go into research.

Konner himself was not immune to the seductions of that power, nor of feeling that his own hardships justified it. He too relished the satisfaction that came from administering a life-saving procedure or bringing a baby into the world. But it was always tempered by a self-awareness that few of his fellow students seemed to have had. What he seemed to know was that medicine's powerful sense of purpose, so simple and overriding, could not always justify the sacrifices of time and energy and personal life -- that indeed other purposes, not as dramatic, perhaps, as answering an emergency code, could be equally worthwhile.

Konner believes in a spiritual aspect to healing, something that has less to do with heroic measures and pioneering techniques than with patience and courage and faith. It is the absence of those values in the medical world, along with the personal sacrifices he was unwilling to make, that apparently has driven him away from medicine. His departure should make us a little less optimistic about the capacity for change of the profession he left behind.

William B. Hamilton is deputy national editor of The Washington Post. In 1985, he took a leave of absence to take premedical courses and apply to medical school.