A Dickensian medical education

Gregory Rutecki
Lyndhurst, Ohio, USA

 

Illustration for Nicholas Nickleby by Hablot Browne. 1839.

My four grandparents were Polish immigrants who came to America in the early twentieth century. They had no formal education, neither in Poland nor in their new home in Chicago, but worked hard and saved money to pay for the college education of their grandchildren. Life was not easy for the blue collar generation surviving the Great Depression. My paternal grandmother cleaned hotel rooms. My grandfathers were both steelworkers. My maternal grandma was a stay-at-home mother. Despite the odds, they did their parts flawlessly and I owe them a debt I cannot repay. But my own role in their dream was a long road with many a winding turn, reminiscent of the heroes of my literary model Charles Dickens.

My eight grammar school years were inhabited by a variety of Dickensian educators. My first few grades had teachers resembling Mrs. Pipchin of Dombey and Son. “It being part of Mrs. Pipchin’s system not to encourage a child’s mind to develop and expand itself like a young flower, but to open it by force like an oyster.”1 The middle school years found mentors trying to earnestly imitate Dickens’ Wackford Squeers.2 He never “spared the rod” and my early teachers did not either. Even now I continue to have nightmares about my sixth grade visual acuity examination. Unbeknownst to my parents and me, my ophthalmological malady was undiagnosed myopia. The screening tool was simple enough; variably-sized letters “E,” to which a quick response was merely a facile identification of the direction each “E” was pointing. That would have been well and good if I could see them, but I could not. I always occupied the first seat in each grade since I was shorter than my classmates, so the blackboard was never far away. A few squints here and there and I could see clearly enough to squeak by. After three mistakes, rapidly followed by three strikes to the face and back, the last, but correct differential diagnosis was finally entertained and I was diagnosed with myopia. Refractive lenses fixed the problem, however no apologies would be forthcoming from any of my “educators.” Corporal punishment continued to be the rule in the last two years. Rulers and counter brushes were the disciplinary tools of choice. I survived eight years of grammar school without any particular distinctions. To call it an academically-challenged environment was an understatement. It seemed as if my teachers’ ability was equivalent to that of Mrs. Wopsle’s great aunt.3 She was never recognized as teacher of the year.

High school was only slightly better. My educational “motivations” would no longer be “physical,” but it was still an intensely demeaning and emotionally-charged chapter in my life. Most of my classmates were from the better suburbs of Chicago, not the blue collar south side like me. They, like Bentley Drummle in Great Expectations, viewed me as an inferior, just as he did Pip. I earned the nickname “Dumb Polack.” Despite a lackluster academic performance my first two years (barely made the upper 50% of my class), in my junior year, I buckled down and expressed my desire to become a physician. My Achilles heel was mathematics. My best friend, with a real knack for math, was excited to mentor me. An examination was administered two months later. I finished quickly and with a perfect score. This was a novel experience. Aware of my checkered past, the teacher announced that my success could only be explained by cheating and the test results would be null and void. I view “Professor” Crawford of Finding Forrester as a leftover from David Copperfield and Nicholas Nickleby. Crawford reflected the animus of my math teacher. A surprise test two weeks later — with my very own Professor Crawford aggravatingly seated next to me — led to the same results — I was first to finish with a score of 100%. My reward was having my exam torn up in front of the class, the shredded paper tossed on the floor. The teacher unceremoniously left the classroom without a word. It was apprised that I was “too dumb” to study medicine after my ACT and SAT scores returned. My “academic advisors” had surrendered. A rejection from a lackluster community college followed. I was finally accepted by a single, solitary college. My grandparents were thrilled.

In college, I felt like the narrator of songwriter Jason Isbell’s Last of My Kind. “I tried to go to college but I didn’t belong, everything I said was either funny or wrong.” That said, I made friends and received emotional support on many levels. There was a problem though. My first MCAT was marginal at best and all my applications to medical school rejected. After a second, better MCAT score, I was accepted by a single, solitary medical school (obviously, there is a pattern here). A friend of mine characterized our common medical school as “plebian.” However, there was a definite advantage in being plebian. The medical school furnished teachers who cared. Although my intellectual cylinders finally began to fire, during my third year internal medicine rotation, I experienced one final humiliation, again at the hands of a “teacher.” Internal medicine’s monthly ward rounds were consistently preceded by a question from the cantankerous Chair, directed at a single — visibly anxious — junior student. I was the target one day and proceeded to answer incorrectly. My Chair had hatched a plan for my obviously much needed remediation. It harkened back to the palpable embarrassments of grammar and high school. It was a joke at my expense and he never intended his directions to be taken literally. Nonetheless, it was the equivalent of a stinging rebuke. The assembled — medical students, residents, nursing, and pharmacy students — all snickered. He would provide me with measurements for two pieces of plywood — one to be displayed on my front and one on my back. With a white background and red lettering, I was to write: I am an example of the failure of my mentors to adequately educate medical students! Mr. Creakle adorned David Copperfield with his visible sign as well. He was stigmatized as a “biter” and now I publicly failed again intellectually.4 What was even more disconcerting, this was the same Chair that instituted a public punishment at medicine grand rounds, one that I never had to endure. That educational innovation evolved into an embarrassingly redundant weekly spectacle. There would be more than seventy-five witnesses each time. A solitary question would be posed to a “singled out” junior student. If answered incorrectly, the miscreant sat on a stool for one hour sporting a dunce cap, immediately behind a distinguished presenter.

My residency was a “coming of age.” After finishing in the top ten of my class in medical school and being inducted into Alpha Omega Alpha, I finally encountered role models who unselfishly invested in my success. They were educators to be emulated. If I worked hard, I was rewarded. That was easy for a blue collar kid to fathom. My past educational shortfalls and indignities were forgotten. Despite my spotty background, I turned out to be a gentleman (just like David Copperfield, Nicholas Nickleby, and Pip) and a physician. I was painstakingly taught how to review peripheral smears by the hematologist who discovered hairy cell leukemia. I auscultated with the cardiologist who described the postural alterations in the regurgitant murmur of mitral valve prolapse. One of my chief residents attained the highest score in the nation on Boards of Internal Medicine. He was the program’s icon. He respectfully challenged me to emulate his enduring and indefatigable commitment to learning medicine. He never let up, but made the challenge enjoyable. He always treated me like an equal even though I was not. His exhortations contained a playful caveat. He told me once that no matter how hard I studied, I could not reach or bypass his lofty heights. He was so right. Later, with heartfelt examples from my residency, I too developed sincere mentoring relationships. A college student whose dream it was to go to medical school froze and bombed his first MCAT. Since it was a matter of “been there, done that,” I convinced him to take it a second time. He ended up graduating first in his medical school class!

I had taken on the persona of an authentic “Hippocratic” medical educator — that image having been graciously bestowed by my exemplary teachers. A quote from Great Expectations captured the dizzying paradigm shift, “I must be taken as I have been made. The success is not mine, the failure is not mine, but the two together make me who I am.”5 I could never forget or repress the humble roots I came from. To my mind, there would never be a student in my class, or on the wards, who was starting in a position inferior to mine. I taught well because I had been glacially slow to develop and could connect on anyone’s level. Everyone had untapped potential and deserved my best. There is another quote in Great Expectations that I use describing the essence of the student and teacher dynamic. Dickens did not intend it that way, but with poetic license, it has informed my career as physician-teacher. Please read it with its “Herbert” portraying the struggling student and his teacher as narrator. “We owed so much to Herbert’s ever cheerful industry and readiness, that I wondered how I had conceived the old idea of his inaptitude (sic), until I was one day enlightened by the reflection, that perhaps the inaptitude (sic) had never been in him at all, but had been in me.”6

I am now retired, but return part-time to teach young physicians. After many years, my students still keep in touch and thank me for my commitment to their success. I may have begun as the Oliver Twist of students, asking for the “more” that finally came, but I am happy where it all ended up. As Dickens said in Little Dorrit, “You will profit by the failure, and will avoid it another time. I have done a similar thing myself… Every failure teaches a man something, if he will learn.”7

 

References

  1. Dickens, Charles. Dombey and Son. Bradbury and Evans, Bouyerie Street, 1848, page 74.
  2. Dickens, Charles. Nicholas Nickleby. Everyman’s Library, Alfred A. Knopf, New York, 1993, pages 99, 76, 39.
  3. Brooks, Peter. Design and Intention in Narrative: Reading for the Plot. Harvard University Press, Cambridge, Mass. 1984, page 131.
  4. Dickens, Charles. David Copperfield. UBS. Publishing Distributors, 2004. 6
  5. Dickens, Charles. Great Expectations in The Works of Charles Dickens. New York, Harper and Brothers, Publishers, 1876, page 121.
  6. Ibid. page 186.
  7. Ibid. Dickens, Charles, Everyman’s Library, page 421.

 


 

GREGORY RUTECKI, MD, retired from the Cleveland Clinic in May 2018 and continues to teach Internal Medicine residents. He was Master Teacher at the Northeastern Ohio Universities College of Medicine (now Northeastern Ohio Medical School) 1996-1999, and Evelyn V. Hess Master Teacher, Ohio A.C.P. 2016. He also received the George W. Joost Outstanding Clinical Teacher Award from The Feinberg School of Medicine at Northwestern University in 2001.

 

Spring 2019  |  Hektorama  |  Education