A Difficult Time
My Journey in Medicine	by Jerry Sobieraj, MD © 2001
Available at and Published by
Also available at:

Chapter 3: Wayne's World

My wife feels it was prophetic that I went to Wayne State University (Wayne). We met on the first day of school, as the alphabet found us in close proximity. I had decided that the first week of med school was going to be largely review, so I had planned to go back-packing on the Bruce Peninsula in Canada instead. She was sufficiently impressed by my disregard for being anxious about starting med school that we hit it off. However, the fact that our first date was to watch the horror of the Reagan landslide over Jimmy Carter, wasn’t a great way to start. Yet we made it through together, and without her, I wouldn’t have spent the past 17 years in Boston, which has been a good experience overall (as a patient of mine once said, "Detroit is a good place to be from").

Medical students tend to segregate themselves early into their destined specialties. I was always an abstract thinker. Thus, I found biochemistry, immunology and physiology interesting. Anatomy was boring, something to be tolerated as we learned where things were in the body. This made me destined for internal medicine. What about the people (largely guys) who liked anatomy? They became surgeons. If they were jocks in addition to liking anatomy, orthopedic surgery (especially if they liked to crack jokes during physiology seminars).

My attraction to Medicine was inevitable. I suspect I would have done some minor things differently if I had to do it over again. Yet even today, I suspect my interests would have drawn me to math and science, again. Over time, the math and science would have became highly technical as I moved into advanced courses. At that point, I would craved the biologic aspect of my studies once again, to sustain me. Since I liked working with people, and didn’t like the idea of being stuck behind a laboratory bench top mixing solutions, I was destined to be a clinician. It seems it would have been hard to alter that pathway, even today.

In reality, my background was quite diverse, which ultimately was an asset when I became a primary care physician. My working class background made familiarity with the views and habits of working people second nature. The summers I spent working in auto factories provided close contact with a breadth of ethnic diversity. Also, my experience at UM gave me the background for dealing with educated people. In fact, my medical training had best prepared me for dealing with educated people. However, it was having facility with uneducated people, or people of simple means and understanding, that was never taught. My background gave me comfort in this regard, allowing me to communicate instinctively with less educated people.

Another thing we learned in med school was how to deal with the medical system. As in all professions, there was an order to our medical system. The paths that people (our patients) took through the medical system could be defined, learned, and when appropriate, repeated. We learned how to structure our days so that we could have our clinical interactions mixed in with other activities. In med school, the non-patient care activities were educational sessions referred to as didactics. The didactics could involve attending a class or lecture, or simply reading clinically related material. Later, when actually practicing Medicine, the other activities would include some administration/paper work (often onerous), and/or research/teaching.

The evolution of a medical student into a resident (a.k.a. house officer) was a truly laissez-faire process. There was essentially no pressure dictating what field one went into. Despite this, as I alluded to above, there was a tendency for an unconscious matching of personality type to specialty. One of the advantages of going to a state school like Wayne was the large class size. In fact, the 256 students in our class was the largest of any in the country, but typical for Wayne. Thus, a broad range of personality types were represented. Some of the more socially inept aptly chose non-patient care fields such as pathology or radiology. This was good, as it would have been frightening to think that some of my classmates would actually be taking care of people.

We were taught in med school to listen to people. We were taught how to ask questions, both to get useful, unbiased information, and to obtain it in a sensitive manner. We truly could learn these skills, even if we came to med school without them. The characteristics we were required to bring with us to med school included a sense of caring, responsibility and patience. In many ways, time didn't matter. What else would we be doing anyway, playing softball? Few of us were married, and fewer still had kids. So we could begin to devote ourselves to our careers.

Unfortunately, as we became more integrated into the clinical realm, we learned other less desirable behaviors. We learned that when you are running out of time, you ask a short, specific question, and hear only what you think is important in the response. We learned how to get patients through the system, as though we had created the system ourselves. Some of these skills would be necessary for survival, and others would become practical aids, a part of our profession.

We began seeing real patients during our third year of med school. These were people who were sick or seeing their doctor for a specific reason as opposed to the people who were paid to act as patients during our earliest clinical exercises in the first and second years of med school. During these early visits with real patients, we were given ample time to accomplish our goals. We learned how to take a history and perform a physical. We learned all the questions necessary to fully evaluate a system of the body, such as the cardiovascular system. We learned specific procedural skills (e.g. drawing blood) and physical exam maneuvers (e.g. how to detect ascites, which is fluid in the abdomen). As we progressed through our training, we had less and less time to see each patient. This was the beginning of the process of efficiency. The underlying, and I believe, still untested assumption in medical training which posited that by gaining experience, we would become more efficient (and thus, faster).

Indeed, I am sure we became more efficient. In part, this was because we learned what not to ask, as well as which questions to ask. This saved time, as we gave the patient fewer questions to answer. In addition, theoretically we arrive at a diagnosis more quickly, and perform a physical exam more ably. However, an alternative hypothesis would be that an experienced physician would take even longer per visit over time. The experienced clinician would see nuances the youngster missed, and thus, would be compelled to follow up on them. In addition, the experienced clinician would have a greater wealth of information to share with patients about their particular issues, due to the physician’s greater breadth of knowledge. Today I could tell a patient much more about a high cholesterol level than I could have 15 years ago. This was in part, because I knew more about what it meant in a practical sense, but also because I had seen 15 years’ worth of data played out in front of me, building on the historical mound of information I accrued as a medical student.

In summary, the not-so-subtle, real life lessons we learned at Wayne were just as important and equally assimilated as the specific knowledge our instructors taught us. They said their goal was for us to become caring, dedicated physicians. Yet the system they introduced us to began to erode those precepts before we even graduated. From there, it was just a matter of time before we learned the way things really worked in Medicine. We could no longer avoid the underlying forces that drove the health care system we had entered. We would become masters at processing patients.

Table of Contents