Why Does Everyone Love a Brain Surgeon?
Many medical students and doctors will recognise the age-old criticisms of medical specialties bandied about from the ward and operating theatre to parties, lecture theatres and even the mass media. Is the geriatrician really a ‘weedy, slow-moving no-hope[r]’ as one gastroenterologist observed, and as a consultant surgeon suggested, an obstetrician simply a ‘midwife with a scalpel’? How much of this condemnation of other specialties within hospital medicine can be put down to being ‘friendly banter’ and how much detrimentally undermines the professionalism between sub-sectors of physicians and surgeons? Does this ultimately filter down to affect the medical student and even the public perception of the role of certain types of doctor?
Specialty ‘Bashing’; A Global Problem
A study published in Family Medicine suggests that the ‘exposure to non-constructive criticism of medical specialties’ is a global phenomenon experienced by most students on their clinical attachments. Discussing studies from America and Australia, it is said that inter-specialty bashing influences career selection to the extent that trainee doctors are more likely to change their specialty choice when hearing a negative comment than a positive one (1).
Having heard derogatory remarks from doctors on the wards from ‘haematologists are boring sods’ to ‘A and E doctors just refer everyone on’, I too found that specialty biases mentioned, subliminally affected the way I perceived my own career path. I wondered whether this was a universal issue for students and if these negative stereotypes were as significant for physicians within the hospital.
This consequently led me to think about the magnitude to which specialty typecasting may have manipulated the general public’s opinion. Perhaps television programmes such as House, E.R and Scrubs which cater to an international audience could encourage the idea, if it exists, of a hierarchal medical framework.
I gathered perspectives from twenty acquaintances comprising of other students, physicians and the public to consider the implications of medical specialty bashing.
Students’ Experiences; Truth or Teasing?
Colleagues I questioned on this topic mentioned a variety of derogatory remarks heard on their specialist rotations from ‘never trust radiologists’ to ‘a psychiatrist is someone who knows nothing and does nothing’ and ‘orthopaedic surgeons are incompetent Neanderthals.’
Some were outraged and disillusioned by their encounters either from the fact that the doctor in that particular specialty felt able to make the derogatory comments or from the off-putting characterisations made of other specialties. Student responses to this heard ‘bashing’ ranged from ‘come to think of it they’re all bullies’ to ‘I’ve been put off from choosing surgery now’. However, others qualified it by surmising that ‘each speciality is valued in its own right’, and thus the criticisms only represent friendly teasing that is ‘fun to join in’ on. Interestingly, all student respondents requested to remain anonymous, even those who approved the inter-specialty mockery. This suggests that perhaps the rivalry is not quite as genial as they may like to believe.
Doctors- ‘We all Bash Psychiatry’
I found that most hospital doctors I approached accepted that ‘bashing’ of other specialties occurred, but were hesitant to support a hypothesis that this repartee may hint at any form of hierarchy. They favoured more politically correct statements such as ‘all specialties in every hospital provide crucial services’ and ‘we consider ourselves to be in equal footing irrespective of what we do, or what kind of patients we care for’. Tellingly, the majority of those same physicians and surgeons were able to list in their opinion, when prompted, the ‘most respected’ and ‘least respected’ specialties in the hospital, whilst denying this represented any form of ranking. Additionally, these doctors all had differing opinions on who was the source of the badmouthing from ‘Intensive care, for some reason they see themselves as the saviours of the hospital’ to ‘general surgeons’ and ‘we all bash psychiatry’.
Only one, an orthopaedic surgeon, went against the trend by emphatically stating his agreement of an unspoken, unofficial hierarchy to the extent that he produced his own league table of specialties from ‘best’, to ‘worst’. He said that although medical branches have their own pecking order, separate to that of surgery, ‘there is no denying that there is one’. In choosing his own specialty, he reminisced that ‘despite being amongst the top students’ in his year, when he elected for orthopaedics, everyone ‘from classmates to professors’ thought he ‘had gone bonkers’. His motivation for bucking the trend was simple love of the job. However, he believed the effect of peer pressure swayed the ‘cleverest’ from joining in him in this self-directed approach.
Everyone Loves A Brain Surgeon
Speaking to people who had no affiliation with the health service I speculated whether I would gain an alternative viewpoint. The consensus was that as the brain and heart represent ‘vital organs of the body’, they were also ‘the most dangerous to operate on’; consequently, doctors working in these specialties demanded ‘the most respect’.
One business student went as far as to say that professionals in these areas had ‘earned the right’ to belittle the ‘less important ones’. A Cambridge University history graduate offered an anecdote which aimed to justify this overwhelming admiration for cardio-thoracic and neurosurgeons by suggesting that her experience of a neurosurgeon’s ‘poor bedside manner’ was a by-product of his ‘talent overriding the need to be civil or comforting’. She believed that ‘brain surgeons spend so long training that you are wasting money and time if you ask them for any information’ and as a patient, you should simply defer to their higher prowess. She mused that ’salary’ should ‘dictate the prestige and how difficult the specialism is’. The most affluent doctors seem, to her, to be those treating the ‘heart and brain’ and therefore it makes sense for them to ‘have the most intellectually difficult training’. They above any other, ‘have to be both technically and academically brilliant’.
The Hypothetical Hierarchy
From the fifteen medical students and doctors I spoke to, ‘care of the elderly’, ‘orthopaedics’, ‘psychiatry’ and ‘pathology’ were most frequently cited as the ‘least respected’ and, ‘general surgery’, ‘cardiothoracic surgery’ and ‘neurosurgery’ as the most. Interestingly this corresponds well with opinion above from the general public about which medical specialties come top in a hypothetical hierarchy, with cardiology and neurology garnering much higher esteem than others.
The Hospital Drama – TV and Reality
Where do these stereotypical views of doctors, by doctors, medical students and the public, come from? They serve to aggravate any inter-specialty rivalry and appear to be partly directed by both personal experience and the media. Medical students are impressionable and it is undeniable that ‘role models, especially amongst medical staff, are very influential’ (2).
One student cited the television programme Green Wing as depicting an environment whereby ‘surgeons are conductors of everything’. Another proposed that their idea of the ‘least respected’ medical specialty was substantiated by Dr Cox in the popular drama Scrubs saying to a patient, ‘Mr. Warner… do you see what you’ve made me do?… You have forced me to [page] the attending dermatologist’ and ‘validate his most ridiculous of career choices.’
A passage in the careers advice book for medical students, ‘So you want to be a brain surgeon?’ addresses the issue of ‘the macho image of the surgical consultant’ enduring in contemporary soap operas. It suggests that they are portrayed as a man who is ‘knife-happy, still offensively rude’ and who ‘exploits a sort of droit de seigneur by bonking nurses and any other willing handmaidens during nights on-call.’ (3)
This image may seem ridiculously outdated but the fascinating thing is that television appears to have a much greater gravitas than one may give it credit for, in ability to subliminally manipulate public and professional attitude (4,5). One fifth year student also quoted Scrubs in stating that when ‘Dr Kelso says to [Doctor Reid] that all women do in medicine’ is go into ‘paed [iatrics] or o[bstetrics] and g[ynaecology]’ this caused her to believe it to ‘be general opinion’ and potentially question her own career path. She also mused that people are ‘brainwashed into wanting to become surgeons’, through the perception of ‘surgeons as the real heroes’ from a ‘glory association’ persevering in newspapers, hospital dramas and films. A study in the Journal of Broadcasting and Electronic Media proposes that television in its depiction of doctors has the ability to control viewers ‘common conceptions of societal facts, norms, and values’ to the extent that it influences their ‘conceptions of reality, standards of judgment, attitudes, thoughts, and behaviour’ (6).
Factors in Choosing a Medical Specialty
If the media can influence both the public and some medical students (even in their final year when they have completed most of their specialist rotations), I wonder whether students are being exposed to specialties in an appropriate way. Certainly, in selecting specialties the ‘reasons are many, various and complex’ as stated by the Royal College of Physicians. Yet, it has become apparent through research and clinical experience, that ‘bashing’ of specialties by physicians themselves and in the public arena through the media, can play a realistic part in medical student preference. Amongst both the students and the doctors I spoke to, all were aware that the motivation in choosing a specialty is made such as on ‘the basis of an individual team’ as well as ‘gender expectations for family planning’ and the opinion of ‘other medical students’ yet concurred that it is ‘the consultants’ views’ that act as a key factor.
Reasons For Specialty Badmouthing
As for why this inter-specialty ‘bashing’ still exists, in which radiologists are belittled to a ‘bunch of switch flickers’ and respiratory physicians ‘sputum loving pedants’, there are mixed views amongst students and doctors. Some see it as old-fashioned prejudices that are ‘ingrained’ in the health system and in this changing cultural environment can only be aired through criticisms disguised as jest. The gastroenterology registrar believes the badmouthing to infiltrate within specialties as well as between owing to the innate natural ‘competitive[ness]’ between doctors which allowed people to enter ‘into medical school in the first place’. Others blame certain doctors in each specialty for having ‘that personality’ to criticise others and a ‘misplaced ego.’ Either way, there is no escaping that ‘the superficial and demeaning comments that students hear about particular career choices’ can act as a ‘hidden curriculum’ (7). This equally, can affect graduates until their specialty choices are made. Dr Foxton in Confessions of a Junior Doctor reminisces about a registrar’s condemnation of Foxton’s psychiatric ambition, by saying ‘they’re a bunch of boring, pretentious weirdos with no life who never answer their bleeps’ (8).
How To Improve Ward Life
Sweeping generalisations such as ‘the medics are the clever geeks and the surgeons are the cool heroes’ may masquerade in jest but both health professionals and the media have a huge obligation to project a positive image of their own specialty rather than badmouthing others, as careers advice as an undergraduate is inevitably coloured and conditioned by staff and their specialties (3). Although it is little spoken about and downplayed by both doctors and some students, it is through an attitude of arrogance and disregard for others choices, whether intentional or not, that a universal hierarchy of specialties has been allowed to persist. Additionally, a review collating medical literature on differences in assumed prestige of hospitals specialties from the 1950s onward, concluded that such a chain of command may eventually influence the priority level of various specialties within healthcare and thus impinge upon patient treatment (9).
With these serious implications in mind, I deem a re-evaluation in the delivery of specialty information to students to be essential, and inter-specialty respect fostered from entry into medical school. Otherwise, students are left floundering in a sea of career choices with little guidance but the opinion and experiences they have clinically to guide them. Nurturing a tolerant attitude on the wards and educating the public is fundamental to redress thoughtless ignorance in the medical system. This will finally allow us to come to the sincere conclusion that all services play a crucial role in national health.
Priya Garg is a 5th year medical student at Imperial College, London
priya.garg05(at)imperial.ac.uk
References:
1. Holmes D, Tumiel-Berhalter L M, Zayas L E, Watkins R. “Bashing” of Medical Specialties: Students’ Experiences and Recommendations. Fam Med 2008; 40 (6): 400-406.
2. Wilkinson T J, Gill D J, Fitzjohn J, Palmer C L, Mulder R T. The impact on students of adverse experiences during medical school. Med Teach 2006; 28 (2): 129-135.
3. Ward C, Eccles S. So you want to be a brain surgeon? A Medical Careers Guide. Second Edition. Oxford: Oxford University Press, 2001.
4. O’Connor M M. The role of the television drama ER in Medical Student Life: Entertainment or Socialization? J Am Med Assoc 1998; 280:854-855
5. Ornelos J, Parikh N. Medical Students Take Heed, They’ll Be Expecting Dr. Carter. American Medical Association Journal of Ethics 2007; 9 (3): 237-240. http://virtualmentor.ama-assn.org/2007/03/mhum2-0703.html (accessed 9 Aug 2009)
6. Chory-Assad R M, Tamborini R. Television Doctors: An Analysis of Physicians in Fictional and Non-Fictional Television Programs. Journal of Broadcasting and Electronic Media 2001; 45: 499–522.
7. Hunt D D, Scott C, Zhong S, Golstein E. Frequency and effect of negative comments (”badmouthing”) on medical students’ career choices. Acad Med 1996; 71 (6): 665-669.
8. Foxton M. Bedside Stories. Confessions of a Junior Doctor. London: Atlantic Books, 2003.
9. Norredam M, Album D. Review Article: Prestige and its significance for medical specialties and diseases. Scand J Public Health 2007; 35: 655-661.