After a weekend in NYC for my cousin's wedding, I went jogging yesterday evening around Ann Arbor.

One of my friends' mom has a theory that she calls the "third generation syndrome." An immigrant from Poland, she, like many immigrants to this country, has spent most of her life working hard to get to a country that is perceived to have more opportunities in the hopes of a better life for her child. Similar to many syndromes, her evidence is entirely anecdotal, only vaguely understood, and based on many generalizations and conclusions (any of which are likely false) that we're all unconscious of. It is not surprising, therefore, that our initial reactions, regardless of how much we qualify it in our minds, tell us that it's true.

Her observations and conclusions: When the first generation of immigration comes from a modest background, they work as hard as they can to get to the US where their children can have more opportunities. As such, they actively and passively instill a sense of importance of hard work and educational achievement on their children. The second generation, having personally witnessed the actions of their parents, and having direct contact with their grandparents, a generation that did not necessarily immigrate, has an internalized understanding of what privileges they were afforded and the importance of capitalizing on them. However, by the time the third generation comes around, if the second generation has been successful, they are now far enough removed from the immigrant generation to understand the hard work that got them to this country, as well as only exposed to the privileged and comfortable life that their parents have created for them. This combination creates a more lackadaisical generation with lower achievement and drive.

I don't know if her conclusions are true. My instincts tell me that sweeping generalizations combined with leapt to conclusions rarely synthesize accurate understandings of the world. However, her thoughts did make me think about something very important: how does one responsibly raise children that come from a privileged environment?

Like many other institutions, the medical school offers medical students that chance to go abroad and volunteer in various humanitarian missions around the world. One of the most popular ways is during your M1 year; there are various groups that travel during spring break and work in charity clinics for underserved communities mostly throughout South and Latin America. It's not surprising that these trips are popular: where else can you get to travel to new and exotic places all while "giving back" and feeling good abour yourself? As an additional bonus, since these clinics are usually the only healthcare available, medical students are allowed far more freedom and liberty to "play doctor."

However, there is always of contingent of eye-rolling, usually well-traveled students who can't help but feel that these trips, however well-meaning, are definitely misguided. There's a long list of grievences that one can pick from including (but I'm sure not limited to) issues concerns for sustainability, care continuity, lack of community self-empowerment/perpetuating the global power dynamic, continuing to support a larger system of inequalities by providing a crutch for irresponsible governments and global citizens, exploiting underserved communities for medical education, over-self-congratulation of what is actually accomplished, and exoticizing poverty and other countries. What's less recognized is that most of us scoffers are not morally superior, we just did all that naive stuff a few years earlier.

Ultimately I begin to wonder, is it possible to educate someone who grows up with privilege without using other human beings as exihibitions? Some have argued it's ok to do so, as long as everybody is aware and honest about what's going on. Or maybe there's a more community empowering way to go about all of this. This question plagues me as important not only from a theoretical standpoint but my own concerns about how to continue to live responsibly as someone with privilege. This question frightens me because somehow I've become old enough to not just ponder these questions in a broader sense, but also in the context of how I hope to raise my kids. That transition of self to kids - ugh - like fingernails on a chalkboard.

I don't know the answer, but I think there are a few things that are definitely true. Humans internalize through experience and relationships. Working in programs that are community led and directed is always better. If a person of privilege is "the star" of the program, something is definitely wrong.

And another thing... This drives me crazy so before we get too far ahead of ourselves in this discussion, I want to call it out now. At some time or another these discussions have been used as a place to wallow in privilege guilt, fuel self-congratulations on how truly enlightened and righteous we are, and generally do nothing but talk about ourselves. I know I'm guilty of this as well. We have got to call party foul on that shit.

At some point a few months ago, I gave a stab at writing that's a bit more mainstream.  Call it an Atul-Gwande-moment.  Ultimately, it was printed in the quarterly Washtenaw County Medical Society Newsletter. I suppose that means it's been peer-reviewed for benign content.
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The progression from a second year medical student to a third is one of great anticipation. To a preclinical student, transitioning to the wards signifies a rite of passage and entrance into the professional medical community. As our second year draws to an end, an undercurrent of excitement grows as we begin to have class meetings about third year scheduling and the dreaded Step I.

In preparation for our time on the wards, and to prove that our physical exam skills are up to snuff, University of Michigan students must also pass the M2 Comprehensive Clinical Assessment. Suddenly, the mild mannered women that we once knew as administrators don ear buds and microphones and become the secret service, guardian of 15 minute sessions testing everything from the cardiac exam and mini-mental status exam to history taking and presentation skills. They snap into their microphones, “Red team, GO!” and “Yellow team, we straight? We go in 3 minutes 19 seconds.” They snap at us, “Don't touch that clipboard yet!” “You can't sit in that chair.” “Ok, now you can sit in that chair if you like.”

However, unlike many of the other tests that we're introduced to, we're never given the sensitivity and specificity of the physical exam tests. A few studies have attempted to quantify certain maneuvers, especially in the setting of PM&R and Emergency Medicine, but if these numbers are known, they're not taught.

The joke about American medicine is that we don't know how to examine patients properly anymore. Unlike doctors in developing countries and Britain, we rely more on labs and imaging. As one surgeon said to a third year medical student who suggested pneumonia in her patient after feeling his chest, “Fremitus?! The most important part of the lung exam is the chest xray.”

You can tell that medical schools are desperately trying to turn this trend around. Every week a different professor says emphatically, “Learn to rely on your history and physical! Ninety percent of your diagnosis is in the H&P!” And yes, that may be true, but if you're hoping to cut costs by sending off less needless tests, it's unlikely. In an age of defensive medicine, even if we take to heart the messages from our professors in our preclinical years, by the time we leave the wards, we'll all be ordering tests just to “make sure.”

However, in the discussion over the importance of the physical exam, debate that seems just as much cultural as it is evidence based, what's overlooked is that no matter how medically important we decide the physical exam is, it also plays an important role in our relationships with our patients. I think there's something innate to humans that responds to a caring physical touch. Though it's not always appropriate to hug or hold our patients' hands, the physical exam gives us a way to physically connect with our patients. Whether it's palpating or percussing, it's a chance to express our compassion for our patient; something that is as important for our patient's trust as it is for our own fulfillment. Ultimately, it's a chance for the patient and the doctor to remember that we're both human; our own little version of the “healing touch.”

After three months of internal medicine, starting off a rotation focused on community and safety net psychiatry is quite a change in not only the patient population, but also the culture of the health professionals. Patients with psychosis are generally in the lower classes of society, though not because lower incomes cause psychosis, but because it's incredibly difficult for psychotic patients to function in society. Thus, it's not surprising that in a safety net program, there's a large number of patients who suffer from delusions and hallucinations of differing severity. As a side note, it's also not a shock to discover that the psychiatric medicine and illness, though portrayed quite commonly in popular culture, are quite different in reality.

One of our patients, Ms. R, was not only the most symptomatic patient I had worked with, but also one who had little to no insight into her condition. Throughout the interview I struggled with my own thoughts. Watching her, I quickly realized that without active resistance, I would slip into voyeurism, as if she were a form of entertainment. Seeing how distraught her sister was with her worsening symptoms often snapped me back to the gravity of the situation, but without any real way of engaging with the patient it was all too easy to forget that she was a human being. This was a disturbing disappointment in myself.

While the appointment started off as friendly, by the end, Ms. R was sure that we were all her enemies. We were trying to increase her dosage of medicine for no good reason and kill her off by ruining her kidneys or sedate her to the point of floppiness. As her anger peaked she turned to me and my attending, a black man, and stated, “You're black and yellow pieces of shit.” She continued to repeat this several times until her ramblings turned into a string of noises and whistling with intermittent references to president Obama. While it was easy to take the comments in stride, this woman clearly wasn't herself, her sister was appalled and extremely apologetic. She insisted that this wasn't her sister and that in reality her sister is “the most loving person who couldn't hurt a fly.” In her eyes I could see the fear that we would not only judge her sister, but her.

It's easy to say that we weren't offended because it's not fair to be upset with someone who's delusional and paranoid – of course, the fact that she was floridly psychotic made the comment much easier to ignore - but it occurred to me that there was something larger at play. The actual content of her statement was not actually racist. The only insulting part of the sentence was being likened to a poop; the usage of black and yellow were simply descriptive. She never explicitly said, “You folks are inferior because you are not white.”

Ultimately, Ms. R wasn't trying to be racist, she was angry and trying to insult us. If we had both been white she still would have likened us to shit in some other way (though she would have had to be more creative). Certainly, it's possible that she has a certain level of implicit bias that is held in check when she's more cogent, but I also wonder if her usage is actually more reflective of society than herself. Insults are only effective when we collectively agree that the leveled comparison is bad. Just as we are (relatively arbitrarily) taught to consider the product of bowel movements to be smelly and messy and thus bad, millions of messages everyday also tell us that being non-white is bad. In her mind, she was just remembering the list of things that she had been taught were bad and using whatever seemed to apply.