Medical Career Choice: A Gender Study : A Gender Study [1 ed.] 9781617285370, 9781606928844

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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook Central,

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

MEDICAL CAREER CHOICE: A GENDER STUDY

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Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

MEDICAL CAREER CHOICE: A GENDER STUDY

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

LUIZ ROBERTO MILLAN

Nova Biomedical Books New York

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009 by Nova Science Publishers, Inc.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Library of Congress Cataloging-in-Publication Data Available upon request

ISBN: 978-1-61728-537-0 (E-Book)

Published by Nova Science Publishers, Inc.    New York

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Contents

Preface

vii

Dedication

ix

Acknowledgments

xi

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Foreword

xiii

Chapter 1

The History of a Medical Career

Chapter 2

Women in Medicine

27

Chapter 3

The Intricate Vocation Issue

35

Chapter 4

Medical Career Choice

49

Chapter 5

The School of Medicine at São Paulo University (Faculdade De Medicina Da Universidade De São Paulo—FMUSP)

79

A Survey of Students from the School of Medicine at São Paulo University (FMUSP)

91

Chapter 6

1

References

143

Information about the Author

155

Index

157

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

Preface The choice for a medical career is a millenary issue. About 2,400 years ago, Hippocrates "the father of Medicine" pointed out the necessary qualities for those who intended to choose medicine as a career. Many of such qualities are remarkably valid to date. In Ancient Greece, women were prohibited from practicing medicine, but today they are the majority in several countries. However, women still suffer discrimination within the medical hierarchy and fewer reach top academic positions. They face great difficulties to be admitted to some specialties; they make lower earnings than men and are distrusted by colleagues and patients. In order to approach such issues, the author makes an extensive bibliographic review, which embodies the medical career history and vocational theories. Then he proposes a methodology for studying the issue and presents the results of a survey made with students in a Brazilian medical school. According to Professor of Psychiatry and Psychology, Paulo Correa Vaz de Arruda, "the experience the author acquired over more than two decades by providing psychological assistance to medical students added to his natural gifts and has resulted in an accurate survey from the scientific viewpoint, which is unique in several aspects, appropriately deep for the importance of the issue and, moreover, brave enough to deal with a problem which, to the majority of Medical Psychology experts, is the most intricate one in that discipline. The book is a valuable scientific compendium, which is now published to fill a gap in our area."

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Dedication I Dedicate this Book To Marília and Laís, two dreams I have never wanted to wake up from. To the memory of my father, Roberto Millan, who succeeded in reaching the deepest sense of medical vocation.

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To Paulo Vaz de Arruda, a generous friend, wise advisor, and an inspiring example of college teacher.

This book was originally published in the Portuguese language by publisher Casa do Psicólogo, Brazil, under the title "Vocação Médica — um estudo de gênero". It was translated, with some adjustments, into English by Laura Faro."

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Acknowledgments I thank Professor Raymundo Soares de Azevedo Neto, who, with admirable dedication and competence, gave me his advice about the dissertation from which this book originated. And, most of all, I thank him for his humanism, sensitivity and friendship.

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I thank Marília Pereira Bueno Millan for her companionship and encouragement ever since the day I chose a medical career; for bravely and wisely defying all frustrations imposed upon a girlfriend, and subsequently wife (but always sweetheart) of a physician; for her always careful reading of the drafts of this book and precious suggestions; and for having performed the Herculean task of interpreting three hundred TAT stories using her great talent as psychologist and psychoanalyst. Not all words are enough to thank Professor Paulo Vaz de Arruda for everything he has been doing for me since I chose the most exciting medical specialty: Psychiatry; for his great friendship, wisdom, generosity, courage, integrity, intelligence, and sense of humor — attributes that make him a unique human being. I thank Eneiza Rossi and Orlando Lúcio Neves De Marco, good friends of mine and fellows of the Psychological Counseling Group of the School of Medicine of the University of São Paulo (GRAPAL), for their suggestions and for conducting the psychological tests. I also thank Eneiza for translating Pierre Schneider’s Regards discrets et indiscrets sur le médicin, a work that so much enriched this book. I thank Vera Angela Belia Tancreda for her competence, availability and for typing this text. I thank one of the most talented researchers in medical psychology Doctor Patrícia Lacerda Bellodi for her friendliness and appropriate suggestions regarding this book. I thank teachers Liliana Segnini, Maria Aparecida Basile, Maria do Patrocínio Tenório Nunes, Carlos Corbett and Wilson Jacob Filho for carefully reading this text and giving their remarkable contributions.

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

xii

Acknowledgments

I thank my kind daughter Laís Pereira Bueno Millan for her smile, for what she is and for what she has always been; for being tolerant with her father, who added countless weekends to his doctor’s routine to write this book. I thank Doctor Laertes de Moura Ferrão who, through his great psychoanalytic vocation, has led me to the unknown universe of the unconsciousness. I thank my friend, psychiatrist and photographer, Professor Renato Luiz Marchetti for his precious methodological suggestions about the project of the dissertation from which this book originated. I thank the physician, psychiatrist and poet Emmanuel Nunes de Souza, my classmate at FMUSP and fellow of the GRAPAL for reading the text and giving his valuable contribution. I thank Professor Milton de Arruda Martins our Para nymph, for his support to GRAPAL’s work and for his efforts toward medical education development at FMUSP. I thank Doctor Inês Sautchuk for carefully revising these texts.

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I thank Professor Eduardo Marcondes, a medical vocation model, who since the beginning of the undergraduate medical course has stood out for his dedication to pupils; for his friendship and for his support to GRAPAL since its creation. I thank the fellows of the Medical Education Development Center (Centro de Desenvolvimento da Educação Médica (CEDEM)) who devote themselves to improving FMUSP services, for sharing so many experiences at GRAPAL since its creation, twenty years ago. I thank FMUSP directors, who since 1986 have given their support to GRAPAL so to allow it to assist medical students in dealing with so many emotional challenges. I thank FMUSP students who generously offered to participate in this work.

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Foreword “...a book which falls within the soul is the bud that makes the palm flower grow is the water that makes up the sea”

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Castro Alves O Livro e a América

Teenagers usually have a wide range of interests that oscillate constantly and give rise to an instability that sometimes leads them up the omnipotent fantasy path, which makes them feel capable of doing everything sometimes and full of anguish other times — the natural fruit of their constantly mutable priorities. This continuous and contradictory movement is a remarkable pattern in adolescence. Such a process happens with teenagers in general, but those having excessively high IQs tend to face stronger anguish crises. To mitigate anguish and in an aim to protect themselves, teenagers look for role models and follow their idols’ path: the awakening of their own “selves”, which is far away from them, is a tempting invitation to constant changes and frequent exchange of positions. This stage, opposed to the evolutionary stage toward maturity, which, instead of changes, has a decreasing range of their abilities as the common denominator. When they reach the young adult stage, their sense of responsibility leads them to evaluate their old interests and increasingly adjust to a new sense of life. These matters — only sketched here — make one think how improper it is to make a vocational choice in this age band, or better, in this stage of life. In developed countries, such a choice is made later; sometimes by the time Brazilian students, for instance, graduate. A resource commonly used is to insert an intermediate course to allow students to make more mature choices in a culturally neutral environment. We had such courses in Brazil in the past, and I don’t know why they have been discontinued. Brazilian teenagers then attended general subject matter classes which allowed them to broaden their cultural knowledge while their range of abilities naturally narrowed down and their omnipotent childlike fantasies were gradually abandoned: their career choice was made in a more realistic way. We all should employ our efforts to bring that model back.

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Foreword

xiv

However, in the meantime, the Millans should multiply in order to advise these young people and mitigate their anguish. In this scenario full of anxieties triggered by uncertainties, the surveys mentioned in this book were carried out. “Man is an eternal apprentice, and pain is his master”. A former young man, or, who knows, an “eternal young man”, although already matured by life difficulties, waived, or at least postponed, an academic goal. And then, “clear” from college influences created by a teacher-student relationship, he could, with smooth tranquility, deal with the vicissitudes teenagers, or late teenagers, go through along their educational path as health care professionals. For the last twenty years, he has been performing such tasks with intelligence, probity and modesty, and obtaining such magnificent results that the Psychological Counseling Group of the School of Medicine of the University of São Paulo (GRAPAL) has become a national reference. Such work is nothing but the natural fruit of a generous professional attitude. The experience acquired over these long years by providing psychological assistance to medical students, has added to the author’s natural gifts and has resulted in a survey strictly correct from the scientific viewpoint, which is unique in several aspects, appropriately deep for the importance of the issue and, moreover, brave enough to deal with a problem, which to the majority of medical psychology experts is the most intricate one in that discipline: the medical career choice! With the advice of Professor Doctor Raymundo Soares de Azevedo Neto, who is a quality seal, Millan prepared his doctorate dissertation, now transformed into this valuable scientific compendium, which is now published in order to fill a gap in this area by approaching the matter of gender in the medical career choice. I am honored and grateful for being given this opportunity and I am going to analyze this work in some of its fundamental aspects:

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•

•

Methodology: I should focus only on the methodology used. Escaping from the prominent sectarianism in psychological sciences, particularly the psychiatry-related ones, where the quantitative methodology nearly always prevails over the qualitative methodology, the author has elected to use both of them. And he appropriately does not explain the use of the qualitative methodology. Both methodologies have a clear scientific nature, one in the numerical sense and the other in the clinical sense. It is time to abandon the “fashionable” exclusive use of Scales to the detriment of Schools: if we do not redefine what Science is, we will keep on improperly using and evaluating clinical criteria, underestimating it: the Cartesian time is long over! If we fail to approach an individual as an indivisible whole, we may revert to past decades and keep on using the rancid dichotomy methods used in Wundt’s psychometric age: we would annul the WHO Magna Session held on April 14, 1948 and go back to the archaic sense of health. I give myself the right to warn younger researchers: the pendulum of history is inexorable. If, in order to be read, a work has to be published in impact journals, its future publications will be faster and virtual, and all researches will find their space. The more they are read, the more they have impact on the public. The impact is to be generated by the research, not by the publishing media. The world is globalized! Internet sites are available to everyone, democratically.

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Foreword •

•

xv

Escaping a little from the methodology, I should say a couple of words about the sampling: restricted, uniform and appropriate; conclusions are referred to as valid for this group only. The work makes way for confrontation with other investigations related to different populations from different schools, in several educational stages, including postgraduate ones. The author calls our attention to all of this. And this is very important, because if a research equivocally concludes that some matter was exhausted, this research is dead: it yields no more fruit! Women in Medicine: what a fascinating chapter! Not only for its serious and competent bibliographic survey, but also for the question raised at the end: Women doctors: are they a threat? The purpose of this work is not to analyze the matter in detail, particularly because it is the product of a Doctoral Dissertation submitted to the obligatory questioning made by an Examining Committee. We all know that the Dissertation, most of the time, is not the best work of the researcher. As such, the Dissertation is fastened, locked and restricted exclusively to the Title given to it. It does not allow further divagations, save in the discussion chapter, where, even so, it should be carefully explained, without the freedom that authors give themselves, where they are allowed to freely and fully express their thoughts, their general or hypothetical ideas.

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The question above, a true hypothesis raised, stimulates the most critical readers. Millan not only raises the question but in a veiled way, although with great erudition and adequacy, also discusses the matter, and quotes the Swiss psychoanalyst Schneider. It is, in my opinion, one of the many outstanding points in this work. It is not restricted to the well-known “machismo”; it also deals with its reasons or at least one of its original reasons: the narcissistic matter. Let me quote, for instance, some of the dissertations presented: − − −

“Marriage between doctors, which is relatively usual, would be a manner to solve the problem of fear and rivalry. Men’s repressed ambivalence and aggressiveness towards women would give rise to a nearly always disguised, poorly conscious rivalry. The presence of women was experienced as an intrusion, a real threat against male doctors and their narcissism. The unisexual harmony that would meet the homosexual tendencies present in all men was then deeply disturbed, which compelled male doctors to acknowledge within themselves, and in their approaches to patients, the importance of the female side of their psychism.”

For what reason would there be “Medical Schools for women” in different times, and in several cultures? For what reason, no specific for-women-only Nursing, Psychology, Physiotherapy, Phono-audiology, or Occupational Therapy schools would have been created likewise? In addition to becoming an excellent perspective for new research, this book paves the way for a more comprehensive approach to the matter: those who devote themselves to study the subject are not only focusing their attention on a medical career but on all health workers. The analysis of the matter of gender in those who devote themselves to health-related careers

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Foreword

xvi

is extremely up-to-date. I have been given the opportunity to raise this question on different occasions: in addition to prejudice, what other elements would be at stake in the well-known preference for one gender to the detriment of the other? Only a deeper analysis of the subject, now made in relation to other health-related professionals, would clear-up the matter. Millan has taken the first step. With the same methodology, if used in the other careers mentioned above, we might have a great comparative study.

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•

The sampling investigated the matter of medical vocation: would it exist or not? In the initial comments of the Discussions chapter, crucial problems are raised and analyzed. As usual, the author makes a serious relevant analysis, which provides readers with a true “neuronal massage”. Let’s see, for instance: is there a medical vocation or not? If so, what importance does it play in choosing one of the several specialties that have emerged with the technological advances in medicine? The affirmative answer to the existence of a medical vocation is explained in the introductory part of the work, where the author appropriately provides the concept of vocation and magnificently explains: “Maybe the concept of medical vocation is too abstract to be expressed in words. It should, therefore, be included in the category of ineffable concepts, just as it happens with feelings — everybody knows their meaning but nobody is able to define them, being enough to describe the situations in which they occur”.

Whether the chosen sampling was appropriate or not for studying the subject matter, the answer, in addition to being clearly provided in the text, reminds me of a great friend of mine, Psychiatry Professor Lopes Ibor. In his magnificent compendium about “Medical Psychology Issues”, he reports a day-to-day life event where some children still attending the first year of elementary school put aside what they are doing and bend to help a female classmate who got hurt: “those who are concerned with other beings’ welfare have, undoubtedly, a medical vocation”. They may study medicine or not. They may belong to the group of those who take care of health in general or not. They may, for several reasons, embrace none of such careers, but they carry the so-called medical vocation seed. Such individuals are everywhere, but unfortunately sometimes they are not found among those who choose a medical career. The selection criteria, which emphasize intelligence levels, the age band in which tests are carried out, and difficulties of another nature, give us no warranty that we are selecting our students by actual vocation or tendency. But such a question should be dealt with another time. Dear readers, the difficulties of life at college are well known, particularly those triggered by a competitive soul that warms up in the fire of vanities. All such difficulties are fully offset by a close acquaintanceship with schoolmates with proper college behavior, which I always define as the ability to live among those having different ideas from ours. However, failing this, the divergences leave the sphere of ideas to follow an improper, sometimes deplorable, path! In this sense, believe it or not: the Dissertation that gave rise to this book, now published, although prepared by a skilled psychiatrist and psychoanalyst, could not be made in the department from which it derived. It seems incredible that in this very 21st century some professionals, sometimes with brilliant academic careers, holders of great overall culture, have become astonished at the qualitative methodology and denied the

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Foreword

xvii

importance of the study of gender in medicine. In turn, the Pathology Department of the Medical School of the São Paulo University (FMUSP) sheltered the author and his work, truly expressing its “college soul”. Therefore, it gave the author the chance to have Professor Doctor Raymundo Soares de Azevedo Neto, a brilliant researcher, as advisor. While the author was submitting his Doctoral Dissertation to the Examining Committee, I was given the floor, which demonstrates the liberality of the advisor, the President of the Committee. I briefly quote some words I said at the time: − −

− −

“Congratulations to the Post-Graduation Committee, which, by selectively choosing examiners has offered as a gift to us a fencing game of intelligence and culture. Your work, Doctoral Applicant Millan, has made me disregard my doctor’s directions, Professor Dário Birollini, who forbade me, a hernia-patient in his seventies, to carry a more than two kilos heavy load: your Dissertation is 30 cm long, 12 cm wide, 5cm thick and weighs 2 kilos and 200 grams. It is a work of importance, with dense scientific content, and brilliantly defended by you. Good musician, this is his best work after composing his daughter, but then he shared a partnership with his wife Marília…”

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Because of its scientific strictness, its conclusions, and particularly the perspectives this work opens, this book has come to stay! Stay to be read as a source of teaching and inspiration. Son of Roberto Millan, a medical vocation icon, Professor Doctor Luiz Roberto Millan, simply Luiz to his family: You had to be Paulo to know how good it is to have a Millan as a friend. While you do not succeed in making this magic, believe in me! Thank you.

—Paulo Vaz de Arruda, M.D., Ph.D.

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

Chapter 1

1. The History of a Medical Career At a not too deep but still unconscious level of the physician’s mind, where drives and ghosts flow into culture, we may find the millenarian tradition of Medicine, with its gods and goddesses, its saints, and its Hippocrates as well. Affiliation will play the role of one of the identity structuring subjects, thereby granting physicians their place in time, that is, in genealogy.

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—Schneider, 1991, p. 57

It is supposed that the prehistoric man interpreted sickness and death as the work of malign spirits of dead persons, or animals killed in hunting. Prayers and sacrifices were intended to pacify those spirits, and then the wizards took their stand. They sought to learn about celestial objects, the healing properties of plants, and poisons. They put on masks to repel spirits from which sickness originated, and also to impress patients, who, in turn, would trust the wizards’ magic formulae, rituals and amulets. Instead of healing, however, the wizards sometimes used witchcraft to cause illness to people, and that is why they became the guardians of the secrets of life and death. So much power placed them in a class apart from the community. A cave painting found in France, dated between seventeen thousand to twenty thousand years ago, represents a wizard in a primitive community: a human figure wearing a deer mask. Wizards were the first ones to trepan living beings’ crania; it remains unknown, however, whether they intended to relieve the pain or withdraw the demon from patients. In fact, several scarred crania were found during archeological excavations (Alexander; Salesnick, 1966; Carvalho Lopes, 1970; Margotta, 1996), which proves that several patients who underwent such surgery survived.

The First Records Carvalho Lopes (1970) teaches us that Sumerian Medicine in ancient Mesopotamia (a southeast region in Asia, located between the Tigris and Euphrates rivers), is the oldest science known to us. With their apogee between 3000 and 2000 B.C., the ancient Sumerian people laid the foundations of civilization. Medicine was then practiced by priest-doctors,

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Luiz Roberto Millan

whose treatises were written in cuneiform (not linear) scripts on clay tablets. Like the old wizards, they believed that gods and celestial objects were responsible for the diseases. The famous code of King Hamurabi, who lived about two thousand years before Christ, sets forth a clear difference between physicians and surgeons, the latter deemed to belong to a lower class. According to the code, priests were in charge of exorcism procedures, while the physicians’ main task was to prescribe medicines. Moreover, the code provided for professional fees and punishments for surgeons’ malpractices, which included hand amputation; a practice that, fortunately, was seldom used. Physicians were then, for the first time in history, seen as professionals having the freedom of action to fight against diseases. They were compelled, however, to comply with the rules established in a sworn statement and submit reports about their activities to the king. Their identification was made by a stamp or seal — a procedure that is still performed in our day!

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The Medical Career in Ancient Egypt Our knowledge about Egyptian medicine originates from Greek and Roman literature and the discovery of papyrus, such as Ebers’s (1550 B.C.), containing medical instructions. Astonishingly, there were eye, head, intestine and internal disorders, among other specialties at that time. In war time, medical fees were born by the government. Supposedly revealed by the gods, treatments were kept in secret books, and only the priests had access to them. The famous architect and builder of pyramids, Imhotep, was also a remarkable physician, and ended up being deified by the Egyptians. Medical science was passed from father to son, and any son would feel deeply honored to succeed his father. Priests taught their rites, and physicians, in turn, taught their recipes to their successors. This particular way of learning resulted from the fact that there were no medical schools. Notwithstanding, the medical knowledge was constantly improved and achieved by those who shared their day-to-day lives with well-known skilled physicians. In general, physicians were respectable and took high social positions. There were medicalsanitation laws in effect and a significant professional hierarchy at that time (Carvalho Lopes, 1970; Margotta, 1996).

Physicians in India According to Carvalho Lopes (1970), Indian cities more than six thousand years of age were found during recent excavations, and it is known that the Indians had broad medical knowledge. Unlike Egypt, India respected surgeons and clinical doctors just the same, and both areas were integrated. Physicians took a place of honor in Indian society, and were required to comply with a code of ethics described in the Yajur-Veda, which was written about 1500 B.C:

Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

The History of a Medical Career

3

“Devote yourself to relieve sick people from pain, even if you are required to sacrifice your own life. You should never cause damage to a patient, not even in your imagination. Strive to improve your knowledge. Do not see female patients without the presence of their husbands; and behave properly. While by his patient’s bedside, the physician shall in no event be concerned with any other matter but the patient’s health. After leaving his patient’s house, the physician shall not be allowed to talk about what he saw inside” (page 62).

The first medical schools in India were created around 600 B.C. Each master had no more than ten disciples. The medical course took six years — just like today in Brazil. Surgery practitioners were required to keep their nails short and wear clean white garments, a custom that unfortunately was discontinued over the centuries and only returned by the end of the 19th century. Despite their neat cleanliness, Indian doctors used to take a tepid bath promptly after arriving to their patients’ house so to remove impurities from the other patients they had seen before. Before a surgery, the surgeon used to practice the surgical procedures on dead bodies so as to reduce risks of a mistake.

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Medicine in China In China, taboos and prejudices prevented physicians from touching their patients, save their wrists. Commonly, women would use a doll to indicate where the problem was. Dissection was forbidden. Anatomic investigation was the emperor’s prerogative. Medical care was a public service and the government was responsible for editing didactic books (Carvalho Lopes, 1970; Margotta, 1996; Scliar, 1996). According to Lyons and Petrucelli (1997), there was a clearly outlined hierarchy among physicians in China: the chief doctor was responsible for treatments and the professional career of the other doctors; some doctors were in charge of prescribing the regimen; other doctors would treat simple diseases, such as headache and flu; and, finally, there were the surgeons. Physicians progressed proportionately to their medical performance. Their knowledge was put under lock and key, being only disclosed to their sons or the ones especially selected for such a purpose. As mentioned, the study of dead bodies was forbidden, which is why the Chinese lacked precise knowledge about anatomy.

The Medical Career in Ancient Greece The Pre-Hippocratic Era In the 7th century B.C., Homer exalted physicians in his epic poems Iliad and Odyssey: “A healing man is worthier than several other men put together; he performs his absolute rational art within a world full of myths and magic” (Homer apud Carvalho Lopes, 1970, p. 82). Accordingly, there are clues that the medicine practiced at that time did not use magic as a major means of treatment and was practiced by professionals. In his Iliad, Homer refers to Asclepius as the best physician in his time. His sons Machaon and Podalirius were also physicians. Over time, a practice-like medicine was gradually replaced by a magical and

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priestly medicine, which is why Asclepius was deified. Legend says that by the order of Zeus, Asclepius was killed by Hades, god of the underworld, because saving people’s lives would steal souls from his reign, the underworld. Exasperated, Apollo destroyed the Cyclopes that had created the thunderbolt that killed Asclepius, and consequently Zeus lost his power. In order to regain his power, Zeus agreed to resuscitate Asclepius as a god who had been taught the art of healing by witch Medea (Carvalho Lopes, 1970; Mazzieri, 1995). From 770 B.C., the first sanctuaries were created where priest-physicians worshipped Asclepius and other gods, and where magic and hunch prevailed. The presence of a snake used in rituals was obligatory since it symbolized an underground divinity and life renewal power because of its periodical shedding of skin. It is assumed that snakes were already considered a sacred symbol among Semitic tribes in Asia Minor, and even today they are considered the symbol of Medicine worldwide (Carvalho Lopes, 1970; Lyons; Petrucelli, 1997; Margotta, 1996). In his book Symbols in Medicine, Mazzieri (1995) tells us that the snake may be seen as a symbol of prudence. It appears in the emblem of the Medical School of the São Paulo University (FMUSP), created by Milward, who worked there as a teacher from 1913 to 1932. In the same emblem, Hippocrates is evoked by the words “kindness, trust, protection and life defense”. The sun, in turn, appears as a central figure and symbolizes life. Also created by Milward, the Oswaldo Cruz Academic Center (CAOC – FMUSP) emblem carries the picture of a snake and the word aphorism. The traditional color of Medicine found in the emblem — green — represents hope, the hope that physicians should not abandon in the development of their researches. The white represents the respect for classical medical wisdom, the purity of the scientific moral and prophylaxis. Finally, the gold represents the value of scientific merits. The temple of Asclepius is supported by four columns, which symbolize Hippocrates, Galen, Bichat and Pasteur. Despite all the criticism, and the subsequent growth of lay medicine, priests practiced medicine until the 4th century AD, when the practice of worshipping Asclepius dissipated with the worship rendered to Christian saints (Margotta, 1996).

Medicine by Philosophers and the Classical Age Pythagoras (580–489 B.C.) exerted great influence on medicine. He set medicine aside from divine worship. Pythagoras founded a school in Croton where several physicians graduated, among them Alcmaeon, who cleared the scientific path for medicine by emphasizing direct observation of nature, and Empedocles, who, according to legend, committed suicide by throwing himself inside a crater. It is worthwhile mentioning that Hippocrates, who opposed the philosophers’ interference in medicine, was little impressed by philosophical doctrines. The 5th century B.C., the so-called Classical Age, is noticeable for the appearance, for the first time in history, of a medical school. The medical school’s identity was related to its geographic location and education methods. Groups of physicians gathered around the wisest ones who devotedly taught them at no cost. Every school had its own concepts and behaviors, and there was solidarity among its members. But although linked to his group, every

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physician had freedom of action and was responsible for his own professional conduct adopted over his usually itinerant life. The major education nuclei emerged in Cos and Rhodes Islands, Cnido and Sicily. The School of Cos stood out for its innovative nature by attaching value to thinking, observation and experience. Many times, the scientific behavior of the School of Cos collided with the School of Cnido’s, which was deeply rooted to the past (Carvalho Lopes, 1970; Margotta, 1996).

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Hippocrates, the “Father of Medicine” Hippocrates (460–377 B.C.) was the main teacher of the School of Cos. He was an offspring of a family having about forty physicians, many of them homonymous. According to his biographer Soranus of Ephesus, Hippocrates was taught medicine by his also physician father. In addition to creating the scientific method in medicine, Hippocrates firmly established the fundamental ethical rules for high quality medical practices. Contemporary with Socrates and Plato, Hippocrates lived in a time where human thinking flourished in art, politics and philosophy. Hippocrates used to teach his students outdoors, under a big plane tree — a place that is still preserved! He traveled a lot, including to Egypt. He used to say that “the doctor’s place is by his patient’s bedside”, a sentence that contemporary medical students frequently hear from their teachers in their courses. Curiously, Hippocrates suggested that physicians should pay visits to patients before noon, because both would be much quieter in the morning. Maybe this is the origin of medical visits in the morning, a habit that remains until the present day. It is surprising that Hippocrates made so many remarkable contributions to medicine at a time in which dissection was forbidden, and only limited knowledge on anatomy and physiology was derived from animal dissection only (Alexander and Selesnick, 1966; Carvalho Lopes, 1970; Margotta, 1996; Brunini, 1998). More than sixty works of the Hippocratic Collection have fallen into our hands, many of them written by his followers. One of these well-known works — The Sworn — is still used in a great number of contemporary medical school graduation ceremonies. His also famous 406 aphorisms describe his clinical experience with infinite wisdom. His first aphorism says: “Life is short and Art long; the opportunity is fleeting, experience perilous, and decision difficult” (Hippocrates apud Scliar, 1996, p. 30). In his recent work, Brunini (1998) lists some important Hippocrates quotes, such as: The wise man is the one who seeks knowledge; those who suppose they know everything are ignorant (p. 61). … It seems excellent to me that a doctor makes a prognosis, because he will become aware of, and inform his patients in advance, the present, the past and the future of their illnesses; and if he informs every detail omitted before by others, his patients will believe that he is closely acquainted with such cases, and will trust him and his treatment… (p. 47)

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Luiz Roberto Millan Treatment of infirmities implies two outstanding points: be useful and do no harm. Our art embodies three aspects: the illness, the patient and the doctor: the doctor serves the art and the patient has to strive against the illness together with the doctor (p. 47).

In regard to epilepsy, which was considered a sacred illness triggered by the possession of an evil spirit, Hippocrates made the following comment: In my opinion, those who deem such illness sacred are like people we meet everyday, namely: foretellers, fake priests, treacherous charlatans, who pretend they fear God and know more than the others. All of them resort to the divine to hide their own incompetence and lack of importance, but are unable to provide aid (p. 62).

We may also find in the work of Carvalho Lopes (1970) some outstanding Hippocrates quotes: It is difficult to have a knowledge that is so complete that only little mistakes are made now and then. A doctor who only makes little mistakes deserves all praises (p. 109). There are in fact two things: science and opinion; the first begets knowledge, the latter ignorance (p. 109).

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You must be attentive to yourself… say whatever may be absolutely necessary… Whenever you enter your patient’s bedroom, keep this in mind: sit appropriately; keep your countenance and appropriate behavior, dress neatly; express yourself briefly and resolutely; watch your manners, keep your self-control, keep calm, be ready to do everything you have to do. I ask you to be kind and take your patient’s resources in consideration. Whenever possible, provide your services at no charge; and if by any chance you have to help a foreigner facing difficulties, give him full assistance…. For where there is love of man there is also love of the art (p. 108).

According to Margotta (1996), after Hippocrates’s death, the School of Cos started to decline because his followers were not comparable to him and transformed his teachings into dogmas. Content was privileged to the detriment of method, which was the greatest contribution left by the master.

The School of Alexandria The School of Alexandria, in Egypt, was the most important education center after Hippocrates’s death. It succeeded in melding Greek science achievements with the ancient Egypt civilization. The school was part of the Cultural Center created by Alexander the Great in 331 B.C., where philosophy, mathematics, music, poetry, history and natural sciences were also taught. Any student who attended such school would gain prestige and recognition. For the first time in history, dissections were regularly made, making possible discoveries about human anatomy.

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The foundation of the famous library of the School of Alexandria in 320 B.C. attracted many Greek physicians who had adhered to the Hippocratic theory and, after concluding their studies, settled in other Eastern cities or in Rome (Lyons and Petrucelli, 1997).

The Medical Career in Roman Times In the beginning, medicine in Rome was magical and supernatural, but after 219 B.C. it was strongly influenced by Greek physicians who had graduated from Alexandria. In the first century A.D., encyclopedia writer Pliny would not spare the doctors: There is no doubt that they are too occupied with our lives to find anything new that would make them earn a reputation… Unfortunately, there is no law against their incompetence; no exemplary punishment is imposed on them. They learn at our bodies’ risks, and in spite of sometimes facing their patient’s death, physicians are the only individuals who are not punished for murder (Lyons and Petrucelli, 1997, p. 248).

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They seduce our wives, grow rich with the poisons they sell to us, learn at our suffering’s expense, and gain experience at our death’s expense (Carvalho Lopes, 1970, p. 123).

Although free citizens practiced medicine, there were also the slave doctors, who served the high Roman class, the government members, or evaluated the performance of the free doctors who, by the passage of time, gained prestige and privileges, such as tax exemption and mandatory military service release. For a long time, medical careers remained unregulated, until Emperor Alexander (222-235 A.D.) enacted laws that, in addition to setting controls over professional practice, regulated education and titling. Education was no longer informal, and a kind of organization employing salaried teachers, who taught in several courses, including medicine, was then created. The first hospitals built were strictly designed for the military. The first hospital for civilians was founded in Rome only in 394 A.D. (Lyons and Petrucelli, 1997). Medicine was gradually divided into branches such as urology, ophthalmology, otolaryngology, among others (Carvalho Lopes, 1970). Celsus (53 B.C.–7 A.D.) was the most famous Roman doctor. He wrote an encyclopedia entitled De artibus, which included treatises on agriculture, military theory, philosophy, law and medicine. In 1478, after Gutenberg created the printing press, the encyclopedia became the first medical text published. Many people do not consider Celsus as a practitioner doctor, but he certainly offered good advice: A skilled physician is not recognized for taking the patient’s wrist as soon as he gets close to the patient, but for, first of all, looking with a calm look at the patient as if he were examining him/her, in order to find out who the patient actually is; and if the patient expresses fear, the doctor should reassure him/her with appropriate words before proceeding with the exam (Lyons and Petrucelli, 1997, p. 239).

Soranus of Ephesus (98–138 A.D.), who practiced medicine in Alexandria at first and became established in Rome afterwards, is considered the father of gynecology-obstetrics. His work had been consulted for fifteen centuries.

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Galen (c. 129 – c. 200), a Greek physician who also studied in Alexandria, in turn, was the most famous doctor in Rome. He was a confidant of emperors Marco Aurelio and Lucio Nero. According to Carvalho Lopes (1970), his father, an architect, had a dream in which Asclepius predicted a great future for his son if he studied medicine. His writings, compiled into 22 books, are one of the most important works from ancient times. His anatomy studies were impressive but contained incorrect conclusions because the knowledge acquired from the observation of animals was used for human beings. Since the dissection of dead human bodies was forbidden, his teachings were not questioned until the Renaissance, and he remained an uncontested authority in medicine for more than one thousand years! (Margotta, 1996) Lyons and Petrucelli (1997) suggest that several factors contributed to Galen’s teachings not being questioned for such a long time: the instable conditions of the Middle Age had brought into play a vehement desire for certainty and authority; Galen, in turn, used to make boasts about himself and attack his colleagues. Dogmatic and didactic, Galen would never leave a question without an answer. His priggish style was appropriate to the need for “the absolute”. His often theological reasoning was agreeable to the Christian Church. Because his work compiled all previous medical knowledge, it was transformed into the primary source of medical knowledge. And, finally, there was the fact that the first compilers who had studied his writings— individuals held in high repute—had mystified his work.

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The Medical Career in the Middle Ages Corruption, oppression of minorities, poverty, and Barbarian attacks were the reasons for the Roman Empire’s decline. Concomitantly, epidemics with catastrophic consequences led the population to not trust in medicine and science. As a consequence, lay doctors fell into decadence. The Christian Church ended up having great influence in the medical area by spreading the idea that giving aid to diseased people was everybody’s obligation, a charity work. According to Christianity, diseases could only be cured by divine intervention, by means of prayers, amulets, images of saints, sacred oils, imposition of hands, and exorcism. In the Middle Ages, only one having an academic education and high social position could be called “a doctor”. Instead of taking care of patients, doctors spent a large part of their time making philosophical speculations about the diseases. Occasionally, they dispensed advice at high fees, but seldom monitored the results of such service. Hand work was considered of lower rank than intellectual work. According to Carvalho Lopes (1970), in the year 805, Charlemagne instituted the teaching of medicine, under the name of physics, as a branch of philosophy. A conservative, repetitive, and scholastic teaching of medicine was then offered in schools and monasteries. For more than five hundred years, the medicine practiced by the monks in their monasteries was the major medical aid organization in the West. They used the plants they cultivated and gave shelter to all diseased persons who knocked on their doors. Over time, they started to come outside the monasteries to pay home visits to patients, thus infringing upon the religious order regulation, which prohibited the monks from getting in contact with the temptations of the world. After a great ecclesiastic polemic, monastic medicine was

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forbidden, which made the reestablishment of lay medicine possible (Margotta, 1996; Carvalho Lopes, 1970). According to Carvalho Lopes (1970), in the Middle Ages knowledge was based on dogmatism and abolition of any and all experimentation, which put an end to the great freedom that characterized the Greek thinking. Here, again, surgery is dissociated from medicine and is seen as a minor art, relegated to barbers and witchdoctors. In this period, medicine not only stopped to evolve but clearly fell into decline.

Arabian Doctors

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Arabian Medicine embodies all countries where the Arabic language was spoken; a region encompassing Persian, Hebrew, Turkish, Arabian, Greek and even Spanish States. Preservation of Greek culture was its major contribution — there were no developments in anatomy, since dissection was deemed a grave sin. Arabian doctors enjoyed social prestige and those deeply engaged in their medical careers would be held in high repute and get financial rewards. Physician members of the Butha-Yishu family were particularly respected and together with Hippocrates and Galen’s translators had dominance in the medical area at that time. There were sixty hospitals in Baghdad alone, and some of them were also medical schools where pharmacology, therapeutics, anatomy, surgery and clinical practice were taught. After attending a course in a hospital or education center, Arabian doctors would receive a certificate from their masters. There were, however, many doctors who received no medical education but practiced medicine until the 10th century, when the caliph of Baghdad ordered that all men, save unquestionably reputable ones, who intended to practice medicine, must pass an exam. Such reputable doctors provided services to noble and wealthy people only (Carvalho Lopes, 1970; Margotta, 1996). Two Arabian doctors were prominent: Rhazes (860-932) wrote 237 treatises about astronomy, philosophy, mathematics, religion and medicine and was considered a genius. His generosity toward the poor and his teachings beside his patients’ bedsides deserve mention. He valued medical authorities’ writings, but if they were opposed to classical knowledge, he would trust his own observation. He asserted that experience was more important than the knowledge acquired from books, and that it would be impossible to reach absolute truth in medicine. Despite the monies and honors he received in his lifetime, he died in poverty and blind as a result of physical attacks ordered by a caliph who had been offended by his honesty! Avicenna (980-1037) started to study medicine when he was only sixteen. At the age of eighteen he was the royal court physician and at twenty-one he had written a scientific encyclopedia. He had deep knowledge of mathematics, physics, alchemy, natural sciences, geology, astronomy, jurisprudence, music, philosophy and poetry. His work, The Canon, was translated into Latin in the 12th century and together with Galen’s work ruled medical thinking in the Middle Ages. Cocaine and wine helped him bear the weight of long hours with books. He caused his own death by using pepper enema (Carvalho Lopes, 1970; Margotta, 1996; Lyons and Petrucelli, 1997).

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Maimonides (1125–1204), a prominent Jewish physician, translated the Canon of Avicenna, the Aphorisms of Hippocrates, and Galen’s work into Hebrew. Some authors attribute to Maimonides the authorship of the “Morning Prayer of a Doctor”, which was, in fact, written by his followers and has many versions, but overall expresses his ideas: “The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all times; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children...” (Maimonides apud Carvalho Lopes, 1970, p. 142). “Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great but the mind of man is ever expanding. Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed.” (Maimonides apud Lyons and Petrucelli, 1997, p. 315).

The School of Salerno

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The School of Salerno was the major lay institution and the first independent school in the Middle Ages. It adopted the rational Hippocratic sense, but dissection was not accepted in dead human bodies, only in animals. The knowledge acquired was written in verse, and such writings were translated into several languages and known throughout Europe: “All health to England’s King, and doth aduife From care his head to keepe, from wrath his heart, Drinke not much wine, fup light, and foone arife, When meate is gone, long fitting breedeth fmart: And after-noone ftill waking keepe your eyes. When mou’d you find your felfe to Natures Needs, Forebeare them not, for that much danger breeds, Vfe three Phyficions ftill: firft Doctor Quiet, Next Doctor Merry-man, and Doctor Dyet” (apud Margotta, 1996, p. 55).

In 1224, Frederico II officially acknowledged the School of Salerno and determined that all medicine applicants should be examined publicly by the teachers of the School. Before that, they should study logic for three years, medicine and surgery for five years, and spend at least one year in practical learning under the advisory of a skilled doctor (Lyons and Petrucelli, 1997). According to Carvalho Lopes (1970), the School of Salerno stood out until 1811, when it was closed because there were no students interested in its course (!).

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The School of Montpellier Founded around the year 100, the School of Montpellier competed with the School of Salerno. Today, it is considered the oldest medical school in the world. As in Salerno, Montpellier’s students were taught classical Greek concepts, and after 1376 they started to dissect dead human bodies. In 1220, Pope Honorius III visited the School and regulated the medical education in France, which was free until then, thus giving rise to many abuses (Carvalho Lopes, 1970; Lyons and Petrucelli, 1997).

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The School of Paris – The Universities According to Carvalho Lopes (1970), between the years 1100 and 1400, several universities were created in France, England, Germany, the Netherlands, and Scandinavia. Nearly always, medicine prevailed over surgery and Christian philosophy and theology had supremacy over nature-related sciences. Founded in the 11th century, the School of Paris was less brilliant and useful than Montpellier’s. It instituted a doctorate for teacher applicants and required them to swear before taking the exam that they would not retaliate against teachers if they failed the exam! In most universities outside Italy, education was provided in modest houses, churches and ranches, sometimes in the teachers’ houses, and even at places where prostitutes lived. The students had to sit on the floor in order to show humility, abnegation, and to get rid of any kind of haughtiness. By the 13th century, thanks to Lanfranc — who suggested that medicine and surgery should be unified and wisely advised that neither of them should be ignored — surgery became more respected. According to Margotta (1996), Lanfranc’s colleague Mondeville (1260–1320) suggested that surgeons should charge higher fees than doctors and advised them that some patients would appear at medical appointments poorly dressed in order to pay lower fees!

Doctors and Communities Despite Lanfranc’s ideas, the separation between doctors and surgeons persisted over the Middle Ages. Both of them formed mutually exclusive communities throughout Europe. Surgeon communities accepted barbers while doctor communities accepted apothecaries and artists (because of the common use of powders in the preparation of pigments) as members. Curiously, this close acquaintance with artists enabled great development of the anatomy during the Renaissance. By the end of the medieval period, in addition to hair care, barbers could extract teeth, perform simple surgeries and treat bone fractures. Surgeons, in turn, had higher education, carried out more complex tasks and were legally known as superior to barbers (Carvalho Lopes, 1970).

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Physicians in the Renaissance The 15th and 16th centuries were a milestone in human history: the limited world of the Middle Ages vanished. Columbus, Vasco da Gama, and Magellan travelled around the world and discovered new continents; Copernicus found that the Sun, and not the Earth, is at the center of the solar system; the press was invented; speculations were replaced by Hippocrates and Plato’s unprejudiced rationality; Humanism, which places man at the center of all concerns and questions, flourished; a great economic development took place, and freedom of thinking is respected again. Medicine could not be apart from such movements. However, unlike other sciences and the arts, changes in medicine were slow and scattered. The development of anatomy and acceptance of surgery as a science, together with the printing of classical books that spread medical knowledge, were the most outstanding events in medicine at the time. Physicians were humanistic and educated, and held in high esteem during the Renaissance. They belonged to wealthy classes and studied at universities. Italian universities enjoyed greater prestige and were attended by many foreigners. Dissection was then increasingly practiced, but in the beginning the discrepancies between what was actually seen and Galen and Avicenna’s writings were not taken into consideration. After 1570, anatomy became a discipline independent from surgery and was taught alone. Opposed to inaccurate error-bearing medical drawings, the anatomic illustrations made by painters reached perfection (Carvalho Lopes, 1970; Margotta, 1996). In the 16th century, medicine was considered to be part of physics, and doctors, who worked hard, were called physicists. Medical appointments lasted sometimes fifteen minutes. The work shift, which included home visits and appointments at the office, started at 5 a.m. and ended at night. Doctors barely had time to take their meals. Fees were charged according to the distance covered, the seriousness of the case, and the financial conditions of the patient. Physicians often accumulated a fortune. Those working in the countryside received a salary and provided free health care to the poor. In small villages the doctor’s work was performed by witchdoctors, charlatans, and apothecaries (Carvalho Lopes, 1970).

Leonardo da Vinci In his lifetime, Leonardo da Vinci (1452–1519) was known as a genius of painting, drawing, astronomy, architecture, engineering, mathematics, physics, and as a brilliant inventor. He dissected more than thirty dead bodies and made around a thousand drawings of such dissections. Unfortunately, such drawings and respective notes were only discovered two centuries after their creation, and there were plenty of clues indicating that da Vinci intended to write an important treatise of anatomy. Because of his scientific ability, combined with astute observation and precise technical skills, he turned out to be, historically speaking, the father of anatomy (Margotta, 1996).

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Vesalius Vesalius (1514–1564) was born in Brussels, studied at the University of Paris and the School of Padua. A teacher of medicine and anatomy, he published his first work in 1538, after Leonardo da Vinci’s death, but persisted in the same mistakes made by Galen. Painter Calcar was his assistant and Tiziano his collaborator. In 1543, at the age of only twenty-eight, he published his second work titled Seven books about the human body structure, which gave rise to a scandal at the university because it contradicted Galen’s work. Unable to withstand his colleagues’ attacks and threatened by the church, he burnt the surveys that he had been preparing for publishing and left Padua to take office as the Spanish Emperor’s doctor, which put an end to his scientific career. For his attainments, he is considered to be one of the most outstanding characters in the history of medicine, and the father of anatomy (Margotta, 1996). According to Carvalho Lopes, 1970, Vesalius’ knowledge and principles were assimilated by Faloppius (1523–1562), his disciple and successor in the chair at Padua. In 1561, in Spain, he was enthusiastic at Faloppius’ findings and wrote encouraging words to his disciple. In 1562 he was astonished at the news of Faloppius’s death and subsequent invitation to resume his position. Vesalius died a couple of years later after being attacked by an unknown infection. Silvius, his master, had suggested that he was insane for correcting Galen’s work. Notwithstanding, his work remained and paved the way for the future discoveries made by Harvey.

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Martyrs of Medicine Servetus (1509–1553) was the first man to observe that the blood coming from the lungs, after making contact with the air, circulates inside the heart. Because of his theory, he was judged a heretic by Calvin and burned alive. Etienne, known as Stephanus, described the venous valves in 1564 and was pursued for heresy. He died in prison after waiting for his judgment for several years (Carvalho Lopes, 1970; Margotta, 1996).

Dare Son and nephew of barber-surgeons, Dare (1517–1590) is considered the major surgeon of the Renaissance. After receiving compliments for healing a patient, he used to say: “I have treated him, God has healed him”, which shows how modest he was. In the beginning, he joined bloody battles, where he was taught how to barber, lancet and make bloodletting. He was, then, accepted into the surgeon-barbers organization, a profession still deemed modest and subaltern, because anyone who worked with their hands would be considered to be a server at almost the same level as slaves. Any surgeon who desired to practice medicine would only be authorized to do so after taking before a notary the commitment to never perform a surgery or assist a parturient! In 1554, Dare got a doctorate in surgery and broke a taboo by ignoring the disputes between doctors and surgeons that, according to him, were so

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paltry. Unlike his colleagues, he praised handwork, and even after his great fame, he retained his modesty (Carvalho Lopes, 1970).

Paracelsus According to Margotta (1996), Paracelsus was born in Switzerland and learned medicine from his father, who was also a physician. He worked as a surgeon for the army. Although it remains unproved, he used to assert that he had studied in Ferrara and had learned his art sometimes risking his own life, and that he was not ashamed of having been taught by vagrants, butchers and barbers. He wisely said that the personality of the physician could have a greater influence on the recovery of patients than the medicine itself. Because of his clinical competence he was invited to teach at the University of Basel, where he burnt Galen and Avicenna’s works for having prevented the development of medicine for centuries and accused his colleagues of disseminating falsehoods. He paid a high price for that and was expelled from the University two years after joining it. According to Carvalho Lopes (1970), Paracelsus fell seriously ill because of a wound he got during one of his frequent bouts of drunkenness and died precociously at 48 years of age, abandoned as a beggar in a hospital. Several postmortem compliments were paid to him.

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The Medical Career in Brazil in the 16th Century At the time of the discovery of Brazil, the healing techniques used by the Indians were similar to the ones used in pre-historic times. Shamans or witch-doctors ministered drugs and practiced exorcism. The Brazilian Indians used several species extracted from the Brazilian flora for healing. The same species were subsequently used by the Jesuits, who little by little, from 1549 through 1759, replaced the shamans until they were banished by Marquis of Pombal’s order. Almost all priests provided medical care by mixing the Hippocratic acquirements brought from Europe with the knowledge they acquired from the Brazilian Indians. Among them were José de Anchieta and Manuel da Nobrega who, like their peers, assisted indiscriminately white, black or red men, women or children. Only a few licensed doctors or physicists who graduated in Coimbra or Salamanca ventured into Brazil. They took office as physicists for El-King or the Crown, the Senate, the House of Representatives or the troop “party”, and worked as private doctors. It is believed that Jorge Valadares was the first licensed physician to practice medicine in Brazil. He worked as a primary physicist in the City of Salvador, State of Bahia, from 1543 to 1553. Physicists who failed to take official jobs enjoyed little social prestige; the same happened to barber-surgeons, who were taught the profession by the elders and who because of a shortage of physicists monopolized the practice of medicine. In the 16th century, the Brotherhood of Mercy founded the Holy Houses for assisting the poor. It is believed that Bras Cubas founded the first Brazilian Holy House in the City of Santos in 1543. Other historians believe that the first Brazilian Holy House was established in

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the City of Olinda in 1540. Until the beginning of the 20th century, always keeping their charitable purposes and receiving donations for their maintenance, the Holy Houses were the main institutions in charge of providing hospital assistance in Brazil. The provider and other managers of such institutions provided assistance at no cost and received little aid from the public treasury. Some of them are even operating today and contributing to the medical assistance and the education of future professionals (Santos Filho, 1966).

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The 17th Century In the beginning of the 17th century, Harvey (1578-1657), one of the most prominent professionals in the history of medicine, discovered blood circulation. He was born in England and studied at the University of Padua. He was a pupil of Fabricius, successor of Vesalius and Faloppius. It is worthwhile mentioning that he never forgot his predecessors. He acknowledged that thanks to Servetus and Fabricius he succeeded in discovering blood circulation (Carvalho Lopes, 1970). According to Lyons and Petrucelli (1997), Sydenham (1624-1689), known as the “English Hippocrates”, was the most important authority in clinics in the 17th century. Despite being aware of Harvey’s blood circulation hypothesis, Sydenham did not consider it, or the microscopic anatomy, useful for medical purposes. The 17th century was not an innovative period for medical education. Teachers followed, in general, the classical works. The criteria adopted for evaluating generally non-respectful quarrelsome students varied from one school to another. In most European countries the degree of bachelor in literature was required for medicine applicants. Licensing and doctorate together could take thirteen years, and the latter granted greater privileges. Many students belonged to the middle class and some of them belonged to the nobility. Entering the university was easier for sons of physicians, while non-converted Jews, bastards and sons of hangmen would face many difficulties in being accepted. There were 24 medical schools in France, among them the liberal Montpellier and the dogmatic Paris, between which a keen rivalry developed. In the beginning of the 12th century, there were only twenty physicians in Russia, all of them graduated abroad because there were no medical schools in that country. While these few doctors assisted the court and royalty, most of the population was assisted by monks, by women with knowledge on medicinal plants, or by barbers. Scientific societies were organized in England and France, and the British Medical School was in charge of protecting the profession by fighting against witch doctors and members of other medicine-related groups, such as pharmacists. Moreover, it supervised fees and set limits on doctors’ sphere of action. In general, in addition to being paid good fees, physicians were regarded with respect and known as members of the intellectual elite. Medicine limitations and some practitioners’ arrogance, however, did not escape writers’ and artists’ mordacious satire. The image left by physicians from the 17th century was featured by arrogance, pedantry, vanity and stateliness. Bewildered by several different theories, physicians gathered into groups, which gave rise to a lot of controversy among competitors. Their viewpoints were confused with their

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personalities. Surgeons would not reach the physicians’ academic and social levels. “True” surgeons performed major surgeries (tumors, plastic, intestine perforation) while barbersurgeons performed bloodletting and healed fractures and wounds. During the 17th century, fabric trader Leeuwenhoek discovered the microscope by chance while using a lens to cut threads. In 1661, Malpighi concluded Harvey’s work by using a microscope to describe the capillary vessels. He paid a high price: two conservative colleagues from the University of Bologna attacked him at home and anatomy teachers insulted him publicly. Although dissection was performed throughout Europe, particularly in dead human bodies acquired from cemetery thieves, public opinion was against it. The 17th century was marked by a deep gap between medical practice and scientific investigation improvements. Doctors were poorly trained and, as we’ve seen, hated innovation. Philosophy, anatomy, hygiene, pathology, botany and surgery were taught at the School of Paris. By the end of the medical course, students would defend a thesis over an entire year. Such thesis defenses became true intellectual fights, and served as argumentation and dialectical exercises. Among the subjects chosen by the students, some were truly bizarre: “Should physicians wear a tunic and have a beard?”; “Do white-haired physicians have more authority?”; “Is love an illness?”; “Should physicians get married?” But in general the subjects related to physiology or pathology. The graduation ceremony, with students wearing rich garments, came next. Many students worked hard to get the money needed to bear their thesis-related expenses, and some married the daughters of their teachers. Honored with the outstanding profession of their sons-in-law, the teachers would help them in their professional ascension. The more doctors grew busy, the more they would acquire value. Just as in other times, however, some patients would decline to pay their fees, which, sometimes, had to be collected in court. The royal French family was assisted by the teachers of the Medical School of Paris or Montpellier, and this increased even more the rivalry between both schools. The physicians then elected became close with the royal family and had access to all palace rooms. Sometimes they were in charge of secret missions. All physicians were required to comply with ethical rules, and open publicity was forbidden (Carvalho Lopes, 1970; Lyons and Petrucelli, 1997; Margotta, 1996).

A Medical Career in Brazil during the 17th Century The few physicists residing in Brazil were mainly Portuguese and Spanish, but there were some Brazilian, French and Dutch physicists as well. Dutch physician Willem Piso (1611–1678) worked in the City of Recife, State of Pernambuco, Brazil, from 1637 to 1644, at Mauricio de Nassau’s invitation. In 1648, he published the first Brazilian pathology treatise titled De Medicina Brasiliensi. Apothecaries and barbers were other professionals engaged in medical activities. Like the physicists and barber-surgeons, the apothecaries were new Christians (converted Jews) with low socioeconomic status, and came from Spain and Portugal. Since there were no pharmacy schools, they learned their workmanship from the most experienced colleagues. After taking the relevant exams, they would receive a letter authorizing them to work officially. Many of

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them, however, would offer their prescriptions without having received the letter, thus competing with physicists and surgeons in the practice of medicine. Barbers, in turn, were the humblest but the most requested medical professionals for carrying out small surgeries. Like the apothecaries, barbers were supposed to obtain an “examination” letter, but such requirement was not always met. Blacks and mulattoes could practice medicine, but if they were slaves they would be compelled to deliver their fees to their owners. There were also the “healers” (lay doctors), such as the Jesuits and the farmers, and the witchdoctors, who used magic and suggestive therapeutics to treat their patients. Physicists and surgeons did not usually perform childbirth. This type of activity was assigned to “midwives”; in general Caucasian or mulatto women belonging to low social classes. In addition to childbirth, these women performed abortions and treated venereal diseases. In 1683, the first Brazilian medical book written in Portuguese by Ribeiro Morão, titled Tratado Único das Bexigas e Sarampo (Sole Treatise on Measles and Smallpox) was published (Santos Filho, 1966).

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The Medical Career in the 18th Century The conservative nature of physicians prevented medicine from keeping pace with other scientific activities during the 18th century. Notwithstanding, it was in this century that charlatanism, which was always present in the history of medicine, reached its apogee. The most famous deceptive methods were employed by Stephans, who charged high prices for a drug which, according to him, would dissolve renal calculi, and Graham, who used electrical artifacts to convince his patients that they could attain successful amorous performance. Mesmer (1734–1815) may not be considered a charlatan, since it is supposed that he acted in good faith. He graduated from the Vienna School of Medicine and disseminated his thesis according to which the planets could influence human health by means of a mysterious fluid, the “animal magnetism”. And based on such a theory, he created magnetic therapy: at his office, in a sumptuous, scented room with special lighting and ambient music, wearing a red silk robe, he would touch his patients who sat in a circle and induced them into a hypnotic trance and, through suggestion, convinced them that they had been cured. Although unaware of what he was actually doing, he paved the way for Bernheim, Charcot and Freud. In the beginning of the century, old medical schools in northern Italy lost their hegemony, and new schools competed for prestige among students. The success of a certain school would commonly depend on its teachers. This is what happened to the University of Jeiden managed by Boerhaave (1668–1738), who converted it into the most important medical center in Europe. A great teacher whose conduct was based on Hippocratic principles, Boerhaave made profound studies in music and literature. Haller (1708–1777), one of his pupils and considered one of the fathers of physiology, wrote books about theology and poetry as well as four novels. In 1761, Morgagni (1682–1771) published a work that founded pathologic anatomy by studying anatomic differences among healthy and sick people and associating symptoms and abnormalities. Lavoisier (1743–1794), the father of modern chemistry, described the breathing process and used its discovery in public health, showing the importance of a certain

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volume of available air indoors per individual. Unfortunately, this man who strived for people’s vital breathing space was sent to the guillotine by the ones he wanted to help. Also in the 18th century, Jenner (1749–1823), one of the most important subjects in the history of medicine, discovered the smallpox vaccine; a disease that over a century killed about 600 thousand people per year in Europe. Once, a countrywoman told him that she would never get smallpox because she had already had bovine smallpox. Impressed at what he heard, Jenner talked with farmers and ascertained the veracity of the information. More than twenty years later, in 1796, a young man, who since childhood wanted to be a doctor and at the age of thirteen was a surgeon’s assistant, submitted his report about the success of the vaccine against smallpox to the Britain Royal Society, which firmly warned and advised him to abandon his investigations in order to protect his reputation. Jenner did not follow the advice and, with the support of his teacher Hunter, published his work two years later, which was acknowledged worldwide. Auenbrugger (1722–1809), a representative of the University of Vienna, recalled that his father, an innkeeper, tapped on the sides of a wine barrel with his fingertips to produce sounds that indicated the level of its contents. With this vision in mind, Auenbrugger concentrated on research in percussion. In 1761 he published a work describing the chest percussion technique, one of the most used diagnosis procedures until today. Held up to ridicule by his colleagues, his book was rediscovered only fifty years later by Napoleon’s doctor and then disclosed to the world. It is worthwhile mentioning that in 1765 Morgan organized in Philadelphia the first US medical school according to the European model. In 1769, the first medical magazine Journal des nouvelles dècourverts sur touts les partis de la médicine was published in France (Carvalho Lopes, 1970; Margotta, 1996; Scliar 1996; Lyons and Petrucelli, 1997).

A Medical Career in Brazil during the 18th Century In the 18th century, some physicists who had graduated in Europe began to attain good socioeconomic status. The “approved surgeons”, after attending theoretical-practical courses in hospitals and taking an exam, received a letter authorizing them to practice surgery and medicine — the latter only in places where there are no physicists — came on the scene. Concomitantly, the first “graduated surgeons” from European medical schools come to Brazil. After the Jesuits’ banishment, the old buildings where the Company of Jesus Schools operated, now sheltered military hospitals where, together with the Holy Houses, barbersurgeons graduated (Santos Filho, 1966).

A Medical Career in the 19th Century In the 19th century, medicine developments became fast and linear, which puts an end to the progress-alternating-with-stagnation pattern that characterized the history of medicine until then.

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Without using a microscope, Bichat (1771–1802) identified 21 types of tissue. He died prematurely, the victim of an infection he got in a dissection room. Laennec (1781–1826), who since childhood showed a desire to become a doctor, graduated from the Medical School of Nantes under the supervision of his uncle, one of its teachers. Studious and astute, he once observed that his patient’s heartbeat would be more audible with a hollow wooden tube placed between his ear and the patient’s chest. And then he invented the stethoscope, one of the most useful tools for physical examination, which is still used today and has become a symbol of the medical profession. Even some important medicine representatives experienced vocational conflicts. Claude Bernard (1813–1878), one of the most important physiologists of all times, who after beginning his professional life as a pharmacist engaged in theater, is a good example. When he showed his play to a Sorbonne’s teacher, he heard the following comment: “My dear young man, you have been working at a drugstore and your head is full of ideas. You like science, not theater” (Margotta, 1996, p. 141). He then applied to a medical school and soon after graduating he was appointed assistant to the great physiologist Magendie. Between 1854 and 1878, Claude Bernard published eighteen books dedicated to physiology and pharmacology. He introduced the scientific methodology into medical research. In the beginning of the 19th century, no hygiene care procedures were carried out inside surgery rooms. A necrosis patient and an appendicitis patient were operated on in the same room, where even autopsies were carried out. A surgeon wearing a jacket with blood and pus spots would gain notoriety, because a dirty jacket would be a sign of the doctor’s great experience! The bad smell in infirmaries was found perfectly natural and was called “surgical smell”. The mortality in amputation events ranged around 90% during war and epidemic times and about 45% when amputation was carried out under “good” circumstances. In addition to such difficulties, patients and surgeons had to face the pain, a millenary problem that since ancient times tormented both of them. To human beings’ great relief, anesthesia was created in the 19th century. Some physicians, chemists, and two dentists contributed to its discovery. In 1842, Long (1815– 1878) carried out three surgeries using sulfuric ether as anesthesia and such practice was gradually used worldwide thereafter. In 1847, Hungarian obstetrician Semmelweiss (1818–1865) wisely observed that women in labor assisted by midwives had low mortality rates for puerperal fever (3%), while the rates for those assisted by doctors or medical students ranged between 10% and 20%. The fact that his colleague died after getting hurt with a scalpel in the autopsy room, and that students assisted in childbirths after participating in autopsy procedures came to his attention. He concluded that a decomposed substance from dead bodies was contaminating women in labor and then requested students to wash their hands before performing a childbirth. The number of deaths was drastically reduced. He brought this fact to the Medical Society of Vienna and was immediately attacked and dismissed from his office. In 1894, some years after dying of septicemia, a monument in Semmelweiss’s honor was raised in Budapest. For everything he did, he is considered to be the doctor who introduced antisepsis based on statistics before the microbial theory was formulated. Without being aware of Semmelweiss’s work, Lister (1827–1912) observed that exposed fractures were easily infected and concluded that the skin was a barrier against possible

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pathogenic agents. He then began to require that surgery rooms be thoroughly cleansed and phenyl acid used to disinfect the skin of patients and surgical tools. In 1867, he published his experiments in The Lancet magazine, which were received with reservation at first. However, a few years later, his work was accepted worldwide, with the outstanding support of chemist Pasteur (1822–1895), the man who proved that microorganisms cause diseases and can be destroyed by heating. He also discovered the vaccine against hydrophobia and was acclaimed as a benefactor of humanity. Antisepsis is followed by asepsis. In 1886, by using Pasteur’s preventive measures, German Bergmann introduced steam sterilization. In 1890, Halsted used sterilized rubber gloves for the first time in surgery. Post-surgery mortality rates dropped drastically and, finally, surgeons achieved their well-earned recognition as doctors. In 1895, German physicist Roentgen casually discovered x-rays, and in 1898, physicist Marie Curie discovers radium, which is a powerful weapon against cancer. Affirming that her discovery was an asset belonging to humanity, she generously refused to exploit it on a commercial basis. In 1900, the 19th century closed with the publication of Freud’s work “The interpretation of dreams”, which tried to probe the depths of the human soul. In the first half of the 19th century, the developments in physiology, pathology and chemistry had no immediate influence on the practice of medicine. Because of their therapeutic failures, physicians were feared by the population, and some of them would even defend the non-regulation of the profession so as to allow patients to choose alternative treatments. In 1807, a small group of U.S. physicians founded the University of Maryland and many followers joined them thereafter. Three or four doctors were in charge of preparing the bylaws, leasing a building and recruiting students through advertising campaigns. The course was theoretical and lasted from eight to fourteen weeks! Schools depended on monthly payments and, therefore, accepted almost all applicant students. In 1847, it was suggested in the first American Medical Association meeting that the course should be extended to six months, but the schools that followed this recommendation saw their enrollment numbers drastically reduced. For this reason, medical education was kept at low levels until the end of the century; except for Harvard, which in 1871 instituted a three-year undergraduate course and a nine-month academic course, and was soon followed by three other schools. In 1893, John Hopkins University radically reformulated medical education by requesting a university title for admittance and establishing a four-year curriculum. In France, medicine practitioners were divided into doctors of medicine, doctors of surgery and public health employees, who had to meet different requirements and pass different exams. In Germany, rules varied according to the region. In Prussia, for instance, there were three classes of physicians: those who graduated from a four-year university course who had to pass difficult exams; the first-degree wounded patients’ doctors, who graduated from shorter courses and had to pass easier exams; and, finally, the second-degree wounded patients’ doctors with less education and easy exams. Usually, physicians received a salary from the government. But they were also allowed to work at their private offices. The irreversible trend toward specialization, which began in the 19th century, was not easily accepted at first because it was a strategy regularly used by charlatans. Besides, it was a hard attack against medical tradition. But because of the pace of scientific development, physicians were no longer able to stay current with all areas of expertise, and patients started

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to seek out experts. Such experts charged higher fees, worked less and, therefore, had a higher standard of living than general practitioners (Alexander and Salesnik, 1966; Carvalho Lopes, 1970; Margotta, 1996; Scliar, 1996; Lyons and Petrucelli, 1997).

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A Medical Career in Brazil during the 19th Century In 1808 Prince Regent Dom João came to Brazil and created two surgery schools, one in the State of Bahia and the other in the State of Rio de Janeiro. Soon after, they were transformed into “Medical-Surgical Academies” located inside the Holy Houses and where “approved surgeons” graduated within five years and “graduate surgeons” graduated within six years. In 1832, Dom Pedro II changed the Academies into Schools of Medicine. The course of study was always ministered in six years and taught physics, chemistry, botany, anatomy, physiology, pathology, clinical practice and surgery, among other disciplines. By the end of their studies, after defending a thesis, the student would receive the title of doctor in medicine. At the end of the century, nine disciplines were included, among them gynecology, psychiatry and ophthalmology. Physicians who graduated from those two schools would replace the physicists from the past and gain social prestige not enjoyed before. Additionally, they began to be held in high esteem by the population in general. With their family practitioner profile, they assisted all family members, either as clinical practice doctors or as surgeons or obstetricians. They were also family advisors for emotional problems and day-to-day difficulties. It is worthwhile mentioning that in 1808 the first medical book was printed in Brazil. It was written by Manuel Vieira da Silva and titled “Reflexões sobre alguns dos meios propostos por mais conducentes para melhorar o clima da cidade do Rio de Janeiro” (Reflections about some of the most appropriate means to improve the climate in the City of Rio de Janeiro). In 1827, the first Brazilian O Propagador das Ciências Médicas (Medical Science Diffusion) magazine was created. Two years later, the Medicine Association of Rio de Janeiro was organized. In 1888, the “First Brazilian Congress of Medicine and Surgery” was held in Rio de Janeiro (Santos Filho, 1966).

A Medical Career in the 20th Century During the 20th century, a medical career had two different stages. The first lasted approximately up to the end of the 40’s. During the first stage, the family doctor, who attended to his patients at his office or the patient’s home and received fees according to the services provided, played a critical role in caring for patients. The technology then available was very restricted, and the doctor’s main role was to treat sick people. Prevention remained in the background. To be considered a good practitioner, the doctor had to be kind, sympathetic and pleasant. A significant part of the population had no access to medical assistance (Greenlick, 1995). After the second half of the 20th century, the medical profession changed drastically. Thanks to the great developments in diagnosis, therapeutics and surgery, life expectancy

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increased, the health of the population was greatly improved, and in the history of medicine, medical achievements were never so significant. Paradoxically, doubts concerning medicine and doctors were raised as never before. Physicians had never been as subject to disapproval as they are now (Hay, 1988; Porter, 1996). For the purpose of offering medical assistance to the whole population, several countries created national healthcare services. In England, for instance, since the end of the 40’s all citizens pay a contribution to the health system and have access to medical assistance. Despite their civil servant status, English doctors are allowed to work at their private offices, which are sought by only 4% of the population. In Canada, so-called Medicare, a program whereby the government collects money and allocates the revenue to Provincial Councils, was created during the 60’s. Non-civil servant doctors work at their private offices and may or may not participate in the healthcare program. Nonetheless, 95% of them participate. Patients freely choose their doctors, and medical fees are paid by the Councils. In most countries, the whole population has access to free medical assistance, which shows that during the 20th century, government authorities started to invest heavily in health services. The US health system is an exception, since approximately 80% of the population is bound to private insurance companies and is not entitled to free medical assistance, which is restricted to those who have no medical insurance. Notwithstanding, the US spends about 13% of its gross domestic product on healthcare services, which corresponds to US$ 3,500 per capita/year (Pinheiro, 1998; Federal Council of Medicine, 1998). In the sixties, US insurance brokers implemented a system known as Managed Care, which initially defended the choice for medical procedures that according to scientific criteria would be the most appropriate ones (medicine based on evidence). Afterwards, the cost effective ratio related to the treatment for each pathology and the cost of a patient’s potentially unhealthful lifestyle were ascertained. Subsequently, a system of rules regulating all medical procedures, from requests for examination to the appropriate treatment to be employed, was created, and funds were invested in preventive medicine (Ferraz, 1998). The transfer of risks from insurance companies to doctors and patients was another element introduced by Managed Care. If a patient, for instance, fails to attend a medical appointment, the patient’s insurance policy cost will increase. For doctors, the so-called capitation payment system designed to replace fees for services provided was created. Health Maintenance Organizations (HMOS), through which an insurance company makes an agreement with a general clinical doctor who performs his/her “gate keeper” duties, were created. The doctor is in charge of taking care of a certain number of “bodies” (this is the nomenclature adopted by insurance brokers!), that is, a population group, and for such purpose the doctor receives a fixed monthly payment. After receiving such payment, the gate keeper provides primary assistance services to patients and ascertains whether they should be examined by specialists or should undergo a supplemental physical examination, or need hospitalization. Since the costs of such procedures are paid in advance, the less money spent with patients, the more money the gate keeper earns. So, the doctor that, according to the system’s rules, is able to play the role of a good fund manager will be rewarded. There are, however, some more expensive health insurance plans (selected providers network) without gate keepers, which allow beneficiaries to choose their doctors, provided that the doctors are duly licensed (Federal Council of Medicine, 1998; Pinheiro, 1998).

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Managed Care has been drawing adverse criticism. Kassirer (1998) points out that US doctors spend more and more time with bureaucratic tasks, such as the drafting of reports and forms, requests for approval for using resources, and phone calls to patients when forms are changed. In order to maintain their income, they work overtime and have little time available to spend with their families, or practice physical activities, or quietly devote themselves to personal thinking or study. In regard to autonomy, doctors’ clinical decisions, such as sending their patients to take lab tests or to be examined by specialists, and even to decide upon the best therapeutics, have been increasingly restricted. By analyzing the gate keepers’ function, Pinheiro (1998) asks: “What kind of assistance may a patient have when the income of such a patient’s doctor depends on the non-provision of services?” And he concludes: “That is exactly where the system’s perversity resides” (p. 48). The author also strongly criticizes the doctors’ autonomy limitations under Managed Care and gives an example:

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In order to undergo the first psychiatric evaluation, a patient must get an authorization from the insurance company. After the evaluation, the psychiatrist must issue a treatment plan, which, depending on the insurance company, is filled-in in two- to four-page forms. The insurance company will then decide whether the proposed treatment is a “medical requirement” or not. If not, payment is denied. If so, clinical reviewers authorize three to six appointments lasting fifteen minutes at the most, for medication check purposes. After such authorized appointments are over, the psychiatrist must issue another report asking for the insurance company’s authorization for more appointments and so on, with three or four appointments being approved at a time (Pinheiro, 1998, p. 49).

Seeking cost reduction and profit increase, Managed Care companies have implemented a medical information record system to control requests for exams and to access the patients’ history and family-related records. They also compare procedures, results and costs among teams of the same hospital and from other hospitals. Those who spend higher amounts are disaccredited (Federal Council of Medicine, 1998). One may conclude that health has become “big business” in the United States (Pinheiro, 1998). Managed Care is also criticized for favoring doctor-patient relationship deterioration. The president of the São Paulo Medical Association expressed his vehement protest against it in a newspaper editorial: What are we — our patients and us — doing here? Is there any space left to us, characters from a remote past conveyed to a present time where medical assistance is a “product” to be “sold”?… Well then, there is no place for patients but “defective” organs. There is no place for doctors either. We are given no time for listening to people in pain; for us to understand the context in which they live, and provide advice to them, and share their difficulties or relieve their pain. We are given no time to be the ones who we once wondered we would be… Distracted in an increasingly absorbing routine, we have allowed the creation of a system that transforms experts into assembly line technicians and general clinical doctors into “Gate Keepers” or fund managers (limiters)… (Gomes do Amaral, 1999, p. 2).

Monteleone (1998) also criticized the U.S. health system and the losses it imposes on medical practitioners’ autonomy with the creation of protocols. He shows his concerns about the future of the medical profession: “would medical students who learn through routines and

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floppy disks have knowledge enough to perform anamneses, clinical exams, or make a diagnosis, or even administer a treatment? Have we robotized medicine?” (p. 10). Some factors have been attributed to Managed Care’s emergence: •

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First, the increasing number of universities, which has excessively increased the number of doctors worldwide. As from the 80’s, this has been causing compensation losses to practitioners (Greenlick, 1995; Cohen, 1996; Medicine, 1997). Thanks to the technological revolution and increasing life expectancy, healthcare costs are out of control. Medicine has become a prisoner of its own success (Porter, 1996). U.S. citizens have never trusted governmental initiatives, which is what facilitated the creation of Managed Care (Pinheiro, 1998).

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The doctors of the 20th century have been facing other problems: insurance companies have transformed medical error issues into a true industry; medical appointments and drug sales are made on the Internet while inspection agencies have so far found no means to repress such activities. By the end of the 20th century, patients became more aware of medical issues and, therefore, more demanding and doubtful in relation to healthcare services (newspaper Folha de São Paulo, 1999; Kassirer, 1999; Rios 1999). Considering the foregoing, one may summarize in a few words and with the aid of three authors what happened with medical careers during the 20th century: medicine was transformed from a knowledge shared among a few highly prestigious independent workers into a public domain information field, a salaried job, a governmental strategy, and a capitalist activity, the “economicine”, such a new bizarre science (Greenlick, 1995; Bittencourt, 1998; Rios, 1999).

A Medical Career in Brazil during the 20th Century According to Machado (1999), in the first half of the 20th century, as in other countries, Brazilian doctors performed their tasks on an independent basis, as family practitioners, and were highly prestigious. A patient would make an appointment with a highly recommended, skillful and experienced doctor and pay the doctor’s fees at the end of it. As from the second half of the century, this reality has changed radically. In the beginning, the government created a social security system and many doctors turned out to be salaried civil servants. Subsequently, group medicine (healthcare associations) and health insurance systems were created. Under such systems, the customer pays a monthly fee to the medical insurance company, which, in turn, bears hospital and medical assistance costs, as the case may be. Associate doctors usually receive an amount set forth by the insurance company for services provided within at least one month after the medical assistance or procedure being carried out. Medical cooperatives are another medical assistance system. Their member-doctors are at the same time partners and service providers. The biggest cooperative is named UNIMED. Once public hospitals represent 30% of all hospitals in Brazil and are not enough to meet the

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population’s demands; the government-owned Unified Health System (SUS) signs agreements with private doctors and hospitals throughout the Brazilian territory. Under the healthcare association system, all doctors have rights and obligations, irrespective of their career stage and professional qualification, and payment is the same for all. The doctor’s technical and financial autonomy is lost and then dictated by the companies’ interests. Great losses are, therefore, imposed on service quality and doctor-patient relationships. Brazil has become an attractive field to Managed Care companies, which have already made the first attempts to become established in this country. The saturated US market, the Brazilian government’s low investments in healthcare (US$300.00 per capita/year), and the excessive number of doctors available throughout the country, which is above the number recommended by the World Health Organization (i.e. 1/1,000 inhabitants), are some of the reasons for attracting such companies (Iriart, 1999; Machado, 1999). It is worthwhile mentioning that this number has increased in the three past decades because of the uncontrolled opening of medical schools. In 1970, there were, on average, 0.48 doctors per 1,000 inhabitants. Furthermore, most Brazilian doctors are concentrated in the Southeast Region (1.64/1,000 inhabitants), South and Center-West Regions (1.23/1,000 inhabitants), while there is a shortage of doctors in the North (0.52/1,000 inhabitants) and Northeast (0.66/1,000 inhabitants) Regions (Machado, 1999; Iriart, 1999). Machado (1999) proposes that the professional life of Brazilian doctors be divided into five stages:

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•

•

•

•

Beginning of the career: a group comprised of young doctors (less than 30 years old), which in 1995 corresponded to 12.3% of the Brazilian doctors, falls under this stage. They are concentrated in the capital cities of the South and Southeast Regions, and more than a half live in the State of São Paulo. They establish their first employment relationship on an informal basis and receive US$786 per month on average. Such stage is marked by a search among the 65 specialties recognized by the Federal Council of Medicine. Some doctors seek sub-specialties. Establishing in the market: this group is comprised of 16.8% of Brazilian doctors, who graduated five-to-nine years before. Many of them conclude their medical residency or specialization course and move to the countryside. The number of patients is still incipient at their private offices, but they prefer working in the private sector, although their presence in the public sector is significant. They engage in three or more activities and earn approximately US$1,053 per month on average. Consolidating their medical career: a group of doctors who graduated 10-to-24 years before, corresponding to 50.7% of the Brazilian doctors. They are up to 49 years of age and are qualitatively and quantitatively established in the labor market. Although they are engaged in the same number of activities as that of the preceding group, their participation in the public sector decreases and their private office activities increase. Their average monthly income increases to US$1,595. Slowing down medical activities: being 50 to 59 years of age and having graduated more than 25 years ago, these doctors seek to reduce their activities and accommodate a public or private job with their now more successful private offices.

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•

They correspond to 11.6% of the Brazilian doctors and their average monthly income is US$2,132. Discontinuing medical activities: this group is comprised of doctors older than sixty years of age and corresponds to 8.6% of the Brazilian medical contingent. They mostly work at their private offices and for the private sector. They are concentrated in capital cities and their monthly income is greater than that of all other groups, that is, US$2,192 on average. By the time the survey was carried out, however, the Brazilian currency (Reals) was overvalued, which may have distorted the results, overestimating the doctors’ income.

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Chapter 2

2. Women in Medicine “Different is not a synonym of unequal.”

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—Liliana Segnini

History shows that since the beginning of civilization medicine has been practiced almost exclusively by men. In Greece, at Hippocrates’ time, women were always relegated to secondary importance. They were deemed incapable of carrying out medical activities; at most, they worked as midwives. In Rome, some women succeeded in being considered as doctors in a society that granted them broader rights than in Greece. In China, obstetric procedures were carried out by women, and some documents provide evidence that some of them were allowed to practice medicine during the Han dynasty (206 B.C.–220 A.D.). In Arabian medicine, women also worked as midwives when male doctors were forbidden to touch the genitals of unknown women. In the Middle Ages, restrictions in relation to women in medicine were the same but daughters and wives of low class physicians practiced medicine in disguise. Further, female members of Christian religious orders were allowed to see patients (Lyons and Petrucelli, 1997). In Italy, the School of Salerno, which reached its apogee by the end of the eleventh century, admitted female students. Some of them were quoted in famous verses of the school, which were used as a didactic method: “Ut ferrum magnes, juvenes sic attrahit Agnes” (Agnes attracts young men as iron attracts magneto) (Margotta, 1996, p. 52). Trotula, one such female student, wrote an obstetrics treatise that was used for five hundred years. Some historians believe that she was not a doctor but a midwife or some famous physician’s wife (Margotta, 1996). By the end of the fourteenth century, in Germany there were fifteen licensed female doctors, and in the next century the number increased considerably because the emperor hired female doctors to treat the poor. In France, in the seventeenth century, Mme. Bousier published the first scientific book about obstetrics. In England, Elizabeth Cellier founded a special hospital for women and ended up having her books burnt because she criticized the

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king. In general, women were not allowed to teach or practice medicine, save in Italy and Germany as mentioned above. James Barry (1797–1867) was the protagonist of an impressive story: a woman who disguised herself as a man to perform surgeries for the British army and enjoyed a noticeable reputation for fifty years. Only in her autopsy was it discovered that she was a woman. Nevertheless, she was buried as a man. In Europe and the United States, in colonial times, medical schools did not accept female students, although some of them worked as midwives or apothecaries. Harrier Hunt (1850– 1875) was not allowed to attend medical classes in Boston and, after overcoming some obstacles she succeeded in getting a doctorate in Homeopathy. After being rejected by several schools, Elizabeth Blackwell (1821–1910) was accepted to a small school in New York. Anticipating that her admission would be denied, the principal asked the students whether she should attend the medical course. Believing that it was a joke, the students gave their favorable opinion to it. The fact gave rise to an uprising in town. Blackwell could then attend the course, except for male reproductive system anatomy classes. She graduated two years later, in 1849. Her sister Emily also faced great difficulties, but together with other women she graduated from Cleveland school and was subsequently accepted by famous obstetrician James Simpson. In 1857, the Blackwell sisters and Marie Zakrzewska, a doctor from Berlin, founded a hospital for poor women and children in New York, which accepted female medical applicants. Mary Putman Jacobi (1842–1906) graduated from the first medical school for women in the world: the Pennsylvania Medical School for Women, founded in 1850. Subsequently, she also graduated from the University of Paris. She worked as a pediatrician with Elizabeth Blackwell and received a coveted award for a deliberately anonymous work. By the end of the 19th century, most schools that were against the admission of women changed their opinion about it. However, academic chairs were always taken by men, and medical societies did not accept women as members. Not until 1915 were women accepted as US Medical Association members. In England, in 1865, after being refused by several schools, Elizabeth Garrett (1836– 1917) became the first woman to get a medical degree. In 1870 she got her doctorate in Paris and enjoyed great professional success thereafter. She took office as principal at the Medical School for Women, founded in England in 1874, and remained in office for twenty years. But Garret was an exception, since women were often rejected by good hospitals. Not until the end of the 19th century would European universities accept women. In the 20th century, women started to share the medical career with men. However, they were refused in some specialties, such as surgery, orthopedics, and urology. They seldom took academic offices. Marie Curie (1867–1934), already mentioned above, was one of the most important scientists in history. Despite winning two Nobel Prizes (physics and mathematics), she was not accepted into the French Science Academy because she was a woman. In 1947, Gorti Cori gained recognition as the first woman to be awarded the Nobel Prize in Medicine for a discovery in the genetic field. In 1977, physicist Rosalyn Yalow, who in the 40’s had her admission to a medical school denied because she was a woman, repeated the deed by developing the radio-immune assay technique (Porter, 1996; Lyons and Petrucelli, 1997).

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Despite all difficulties, from the 50’s the presence of women in medicine could be slowly but gradually noticed. In his literature review, De Angelis (1991) reported that in 1960 only 5% of physicians in the US were women. In the nineties, this number increased to 30%. Female doctors’ academic performance has usually been similar to male doctors’. They concentrate particularly in pediatrics (where they are majority), gynecology-obstetrics and psychiatry specialties. Only 4% of female resident doctors choose surgery. While 90% of the female population in the US is married, only 67% of female doctors are so. They divorce less when compared to the general population but twice as much as their male colleagues. Female doctors have later pregnancies and fewer children than the general population. Female doctors earn less money than male doctors. Their participation in academic life and scientific publications is smaller than men’s (Porter, 1996; Lyons and Petrucelli, 1997). According to De Angelis (1991), Gordin et al. (1991), Kruijthof et al. (1992) and Goldberg (1995), women frequently face discrimination in the profession and are overburdened with the responsibilities for raising children. Osborn et al. (1992) call our attention to the fact that women are promoted to the office of professor four times less than men. A survey conducted with medical students, assistant doctors and teachers showed that women think that their family commitments are a barrier to academic life. They receive less support from mentors over their professional life. In a survey about women’s prospects for a medical career, Kruijthof et al. (1992) report that at Urije University, Amsterdam, female students show greater concern than male students in relation to humanistic issues and their ideals. They fear having to face more obstacles to their career, which are created either by discrimination or by their need to take care of their children. Male students, in turn, express deeper concern for the technical aspects of medicine and knowledge recycling over their career. In their study about interpersonal conflicts experienced by 125 fourth-year medical students, Spiegel et al. (1985) report female students’ complaints about aggressive situations in their dealings with nurses: they were ignored by them, unkindly greeted, treated without patience and questioned about almost everything they would say. In their literature review, Notzer and Brow (1995) showed that in West Europe and in the United States, the number of women engaged in a medical career was increasing year by year, and in East Europe they were the majority, representing 56% of total doctors in the former Soviet Union. Since in the West a medical career was considered to be a male field, some personality characteristics such as objectivity, aggressiveness and ability to deal with emergency situations were greatly valued. Men, however, would be abandoning the medical career because of loss of status, low income and excessive medical service bureaucratization. In the Soviet Union, a medical career was associated with female traits, such as personal involvement, compassion, patience and flexibility, as well as less concern about achieving high status in the career. The numbers obtained by the authors indicate that women are strongly discriminated against within the medical profession hierarchy: in the U.S. only 9% of teachers’ offices are taken by women; in Israel this percentage drops to 3%. Notwithstanding, the authors optimistically believe that an increase in women’s presence in the medical field may bring some positive consequences such as greater humanization of the profession and a special

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emphasis on patients’ psychological aspects, which would improve the doctor-patient relationship. In 1993, in the UK, 51% of the students admitted to medical schools were women; in Newcastle such percentage surprisingly increased to 70%. Today’s female doctors, when compared to female doctors from the past, make slower progress in their career and seldom choose to work in hospitals. Such slow progress could be explained by flexible training programs that do not require complete dedication. And this could eventually be one of the reasons for discrimination against women (Anderson, 1995; Bynde, 1995). In a survey carried out with first-year students in France, Aron et al. (1968) were surprised to find out that most male students stated that a medical career should be followed only by men and they would dislike their future wives’ engaging in a medical career. The author reminds us that in the beginning of the 20th century, the first two female medical students had to enter the school amphitheatre under police protection!

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Women Doctors in Brazil In Brazil, until the 19th century, a medical career was a male prerogative. Lay women could only assist women in labor. The so-called midwives usually belonged to a low social class and learned their duties solely from experience. In addition to childbirth, they performed abortions and treated venereal disease carriers. After 1832, medical schools in the States of Bahia and Rio de Janeiro offered an obstetrics course to women. In 1834, French-born Marie Durocher graduated in medicine, and because she had guided the empress’s labor, she became the first woman to enter the Imperial Medicine Academy in 1871 (Santos Filho, 1966). Maria Augusta Generosa Estrella (1861–1946) was the first Brazilian female doctor. In 1875, at the age of sixteen, she traveled to New York and, after passing the exam, was admitted to the Medical College and Hospital for Women. She graduated in 1881 and specialized in obstetrics, dermatology and pediatrics. Her success filled D. Pedro II, who had sponsored part of her studies, with enthusiasm, and in 1879, by the emperor’s decree, women were allowed to study at medical schools in Brazil. In 1887, Rita Lobato Velho Lopes (1867–1954) was the first female doctor to graduate from a Brazilian school. After having enrolled for a medical course in Rio de Janeiro, she was transferred to Bahia because she was facing some problems with teachers and classmates. At her graduation, she defended a thesis titled Parallel between commendable methods in caesarian surgeries, which drew adverse criticism for discussing a subject deemed unseemly to women (Santos Filho, 1991; Journal of the Regional Council of Medicine (CREMESP), 1999; Oncken, 2000). In 1919, because of the discrimination suffered by female doctors during the First World War, where they would only be admitted to hospitals if they agreed to work as nurses, Elizabeth Blackwell founded the International Association for Women Doctors in the USA. Only in 1960 was the Brazilian Association for Women Doctors, associated with the International Association, founded for the purpose of fighting against women’s discrimination in medicine (Oncken, 2000).

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According to Machado (1999), the need for labor during the two world wars and the fight for woman’s rights fostered women’s participation in all lines of business. Over the forties, only 1% of the contingent of Brazilian doctors below thirty years of age was comprised of women. Such percentage increased to 12.3% in the 50’s, 15.4% in the 60’s, 28.6% in the 70’s, 42.9% in the 80’s, and 48.9% in the 90’s. In the past decade, women represented 50.5% of all doctors established in the Brazilian capital cities. The Northeast region stands out for the greatest female doctor concentration, for all age groups, 41%, while the South Region is the one with fewer female doctors, 26.9%. In 1995, 32.7% Brazilian doctors were women. Brazilian female doctors usually take jobs in the public sector (75.1% x 67.0%) and have smaller participation in private offices (67.0% x 78.4%). Jobs in the private sector, including on-call healthcare (46.6% x 50%), are mostly taken by the male contingent (53.9% x 61.9%). Percentage differences, however, are not great. One of the factors that justify the women’s choice for public jobs is the guarantee for labor rights such as maternity leave, approval for absence and vacation. Furthermore, public sector companies allow greater flexibility as to working hours and productivity. Empirical data show that in Brazil, women face discrimination by their colleagues and by society in general. The number of professional activities is the same for both genders, but women are grouped in lower income bands: while 62.2% earn up to two thousand dollars, only 34% of men fall under that income bracket. The opposite may be observed in higher income brackets: 20.7% of men earn four-to-eight thousand dollars while only 5.2% of women earn such an income. Only 0.5% of the female contingent falls under income brackets above eight-thousand dollars, while the male contingent reaches 4%. The healthcare market is broad and counts on 64 recognized specialties. However, more than 60% of the whole female contingent is concentrated in only five specialties: pediatrics, gynecology, general clinical practice, cardiology, and dermatology. Female doctors constitute a majority in only thirteen specialties: sexology (100%), clinical genetics (91.1%), hand surgery (68.2%), tisiology (65.9%), dermatology (61.1%), allergy and immunology (60.2%), pediatrics (59.6%), rheumatology (58.8%), nutriology (56.7%), cytopathology (54.2%), sanitary medicine (54%) and pediatric neurology (50.9%). There is a strong prevalence of the male contingent in thirteen specialties, which totals 80% or more practitioners: traffic medicine (100%), orthopedics and traumatology (97.4%), urology (97.3%), general surgery (94.8%), head and neck surgery ((93.15%), radiotherapy (87.8%), hansenology (86.3%), neurosurgery (86.3%), plastic surgery (85%), digestive endoscopy (84.1%), otolaryngology (81.6%), anesthesiology (80.9%) and labor medicine (80.2%). Among women, the ten preferable specialties are: pediatrics (24.5%), gynecologyobstetrics (14.2%), internal medicine (7%), cardiology (3.7%), dermatology (3.6%), psychiatry (3.3%), anesthesiology (3.1%), ophthalmology (2.7%), radiology (2.3%) and sanitary medicine (1.8%). Among men, the ten preferable specialties are: gynecology-obstetrics (10.6%), internal medicine (8.5%), general surgery (7.7%), anesthesiology (6.3%), orthopedics and traumatology (5.4%), cardiology (5.4%), ophthalmology (4%), psychiatry (3.4%) and general communitarian medicine (3.1%). In a survey carried out by Machado, 21% of female doctors asserted that their female status had influenced their specialty choice. They complain about social prejudice and

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discrimination. For this reason they seldom choose surgery, except for hand surgery, which requires delicate abilities. They generally choose fields that allow time flexibility and do not demand urgent assistance. The great challenge for women is to combine career, marriage, motherhood and housekeeping. After producing such data, Machado (1999) concludes that the increasing participation of women in healthcare will trigger significant changes in the production structure of services provided and of specialties. By studying the personality of clinical practitioners and surgeons in our environment, Bellodi (1999) shows that among many resident doctors women tend to choose specialties in which they are allowed to perform their “female condition” to take care of others. Men, in turn, choose fields wherein they have autonomy, are able to express their aggressiveness and display their tendency toward competition. A few female surgeons complain about the strong discrimination they suffer from colleagues and patients: Women in surgery suffer prejudice from their colleagues because they think you are there to flirt with them. It is impossible to show competence. Sometimes you enter a patient’s bedroom and he says: ok, doc, but where is the surgeon who is going to operate on me?” (Deposition of a female surgery resident doctor at Hospital das Clínicas, School of Medicine of the São Paulo Medicine University, Bellodi, 1999, p. 99).

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Women Doctors: Are They a Threat? In his exciting work Discrete and indiscrete views at medicine, Schneider (1991) dedicates part of a chapter to discuss female doctors’ vicissitudes. He says that in Switzerland, the first female medical student entered the School of Zurich in 1846, more than one century ago. Nevertheless, the medical institution is in general impregnated with a certain “machismo”, which appears roughly covered in day-to-day life. This becomes evident when a surgery department head refuses to hire women because he deems them fragile and incapable of withstanding the stress inside a surgery room and during post-surgery procedures, and also because they are excessively sensitive and have no self-control. For other services, women are only hired where no man with the same qualifications is available. The same applies to postgraduate courses. And when women are hired, everything is fine if they are not married and have no children. Ironically the author affirms that the big problem has been finally uncovered: women are different because they have children! The ones in charge of education centers easily conclude that women are as efficient, intelligent, hard-workers, wise, responsible and capable as men, perhaps even more so. What would, in fact, be the origin of such discrimination? Why in many schools, such as Lausanne’s, has no woman become a teacher office holder; what would allow them to participate in the Medicine School Council, which makes the most important decisions? In other European universities and hospitals, the situation is not as cartoon-like as it is in Switzerland, but in all places, save the former Soviet Union, there is no gender equality in medical practice at all. In the University of Lausanne, female students abandon the course at a higher number than male students, although they do not fail exams at a higher rate. Their male classmates

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see them as rivals, compete with them, and tell them they would rather get married, have children and devote their lives to them. Relatively frequently, marriage between doctors would be a way to solve the problem. Men’s ambivalence and repressed aggressiveness in relation to women are unquestionable. The rivalry arising thereof is often disguised and almost unconscious. For centuries, the medical corporation has been controlled by men in hospitals, while women have played limited and subordinate roles as nurses, midwives, social assistants, and lab staff. Many of them were nuns. The presence of women was experienced as an intrusion, a threat to male doctors’ identity and narcissism. The unisexual harmony, which would satisfy homosexual tendencies that all men have, began to be deeply disturbed, and then male doctors were compelled to acknowledge the importance of the feminine side of their psychism to themselves and to their approach to patients. Women gradually found their place in a medical career, but only at low positions on the hospital hierarchy. There are other obstacles such as the possibility of working part-time that would allow them to devote time to raising their children, a task which is in general postponed for many years. Also, there is great opposition to maternity leave. The same does not apply to men when they have to leave their jobs for long periods to serve in the army! Motherhood requires women to share their time between their families and medical activities, which is only possible in certain specialties. Maybe the stress caused by cumulative professional and family activities explains why female doctors are at a greater risk of having obstetric complications than the majority of pregnant women. During the education process, female doctors face another disadvantage in relation to their male classmates: they seldom have female role models with whom they could identify —women who have found satisfaction and pleasure in their personal life, with husband and children, and also in their professional career. Furthermore, although men’s opposition to women in medicine is decreasing, at the unconscious level such a change is far slower; the issue here is the male narcissism of each college and hospital team member. Often, women take masculine-like attitudes in order to participate in a male team without disturbing its operation, which does not occur when a female doctor is successful without waiving her feminineness. Women are generally less ambitious in their career than men. They seek pleasure in other fields, such as raising children and having pleasant leisure time. They submit less to constraints and masochist proofs that are inherent to hospital and university office escalation. From this viewpoint, women are healthier than men. Medical and college institutions are well protected places, security upon which some may depend, and maybe they are more convenient to men than to women.

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Chapter 3

3. The Intricate Vocation Issue Verb To Be What are you going to be when you grow up? Everybody asks children. What is “to be”? Is it to have a body, a style, a name? I have the three of them. Am I? Am I supposed to change when I grow up? Should I use another name, body or style? Or we just begin “to be” when we grow up? Is it so terrible “to be”? Does it hurt? Is it sad? To be: quick spelling words and so many things fit in. I repeat: to be, to be, to be. And who do I become when I grow up? Am I required to? Do I have a choice? I cannot understand. I am not going to be. I don’t want to. I am growing up anyway. Without being. Forgetting. —Carlos Drummond de Andrade

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Concept The word “vocation” originates from Latin vocatio and means tendency, proneness, or inclination to follow a career, choose an occupation, etc.; nature, talent, natural spiritual aptitude, choice, election, call, predestination. The original sense of the expression is theological, because it is so designated as God’s call to a certain individual to carry out a certain assignment. This conception has given rise to modern meanings, the ones used both in the current language and in scientific and psychological techniques. Vocation directly relates to two activities: vocational advice, which helps a person to choose his/her occupation, and employment selection, which is intended to ascertain among several members of a group who is the best one to perform certain duties (Merit Encyclopedia, 1964; Arruda and Millan, 1999).

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Vocational Theories Historical Notes

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In his literature review, Campos Silva (1996) reports that according to historical surveys in 1474 Campbell carried out research in London about the careers existing at the time and concluded that every individual had natural talents that would favor the performance of certain works. He wisely points out the importance of pleasure in performing professional activities. He further suggests that parents should allow their children to choose the career that most pleases them. Also in the 15th century, in 1488, Arevalo published his Speculum Vitae Humanae, where he asserts that natural proneness and life circumstances are responsible for a career choice. In the 16th century, in 1568, Sachs and Shopper published a work titled “Accurate Description of all Professions on the Earth”, where not less than 114 professions are described. A few years later, in 1575, San Juan suggests that schools should hire advisors to detect their students’ abilities and advise them as to career choices. In his curious work published in 1585, Garzoni defines profession as any activity performed by a man, even if it is to his own or third parties’ detriment. His list of 545 professions includes vagrancy, greediness, murder, tyranny, piracy, among others. By the end of the 19th century, vocational advising became a scientific discipline thanks to Catell (1890), Binet (1916), and Galton (1928), who created the first technical tools and conceptual bases in this field. In 1902, the first employment selection and professional advisory office was organized in Munich. A few years later, in 1908, Parsons did the same in Boston. During World War II, the need for selecting soldiers fostered vocational psychology: by means of a factorial analysis, one hundred personality traits were detected and subsequently related to several professional activities.

Classification Crites (1969) subdivided the inner processes underlying vocational development into three groups: psychological, non-psychological (sociological, economic) and general (Bohoslavsky, 1977; Ramos da Silva, 1992; Pimenta, 1995; Campos Silva, 1996; Ferretti, 1997). Psychological Theories •

Trace-factor theory: the main vocational theory during the first decades of the 20th century. Conceived by Parsons in 1909, it assumes that there is a right man for the right place; that is, individuals have abilities, interests and personality traits that are appropriate to a certain professional career. The purpose here is to follow a rational professional counseling technique. As from the 50’s, this theory has been criticized for its excessive pragmatism and failure to consider changes that individuals go through during their lifetime.

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The Intricate Vocation Issue •

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Evolutionary or developmental theories: Ginzberg (1951) and contributors proposed that career choice is a process that develops over the first two decades in one’s lifetime. Initially, between 3 and 11 years of age, there is the fantasy stage, when choices are only based upon desire without taking individual possibilities and environmental contingencies into account. During such stage the individual is not aware of what he should do to achieve a certain goal, and in the last stage he tends to imitate adults. The attempt stage begins at 12 and ends approximately at 16 years of age. Initially, the adolescent makes his/her choice based on his/her own interests, then on his/her abilities, and finally on his/her own values. During this stage, the individual does not have too much information about his career choice. Finally, between 17 and 21 years old, the individual goes through the realistic stage, when he seeks to reach a balance between his desires and reality. The realistic stage encompasses three sub-stages: the first is exploration, when several potential occupations are suppressed. During the crystallization sub-stage, the individual elects a career. And finally, during the specification sub-stage, the individual takes the first steps to achieve his goals.

Super (1972) replaces the expression “career choice” with “vocational development”, and divides it into five stages: •

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•

• • •

The growing-up stage lasts from birth through 14 years of age, when the individual identifies himself with family members and teachers. Fantasies are predominant between 4 and 10, interests between 11 and 12, and identification of abilities between 13 and 14 years of age. The exploration stage lasts from 15 through 24 years of age, when the individual investigates his potentials and available occupations. This stage is divided into three sub-stages: the attempt sub-stage (from 15–17) when career choice is made based on fantasy; the transition sub-stage (18–21) when the individual takes reality, opportunity, taste and interests into account; the trial sub-stage (22–24), when the individual chooses among several fields the one he defines as his own and brings himself into direct relation with it. Because college students are generally undergoing the exploration stage they frequently experience vocational crises during the course. The settlement stage lasts from 25 through 44 years of age, when the individual employs his best efforts to settle into the career he has chosen. The permanence stage lasts from 45 through 64 years of age, when the individual has already conquered his place in the labor world and strives to keep it. The declining stage lasts from 65 years old on, when work pace is reduced, its nature occasionally changes, and it is finally discontinued.

According to the author, professional maturity does not necessarily coincide with chronological age. The individual is exposed to socioeconomic factors that limit his options. Individuals have different personalities, interests and abilities, which qualify them for certain jobs. Over the time, their preferences, skills, and work conditions change, and that is why a

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continuous choice and professional adjustment process is required. Professional satisfaction is obtained when an individual finds a career that enables him to develop his abilities, interests, personality traits and values. It is a life-lasting process. •

Directional theories: use decision models formulated by the economy.

In 1962, Gelatt (apud Campos Silva, 1996) proposed that when an individual is required to make a decision there are two or more possibilities among which one must be chosen based on information to be collected. Under the so-called predictive system, the individual evaluates the consequences of a possible decision and the probability of such consequences objectively (by numerical data, for instance) or subjectively (by his own judgment) occurring. Subsequently, under an evaluative subsystem, the individual evaluates whether such consequences (pleasure or displeasure) are desirable. The decision criteria consist of a strategy that seeks benefit maximization and cost minimization. In 1968, Hershenson and Roth (apud Campos Silva, 1996) would call our attention to the fact that when an individual defines himself towards a certain direction, he becomes increasingly tough to reconsider his choice because he is psychologically determined. •

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•

Psychodynamic theories: they use the psychoanalysis theory to understand the career choice process. Because of their great complexity they are discussed separately. Typological theory: conceived by Holland (1973), the typological theory proposes that career choice results from an interaction of several factors, such as hereditary characteristics; experiences with relatives, significant adults and friends; social class; cultural and physical environment. Similar personalities and life histories favor a certain vocational development. Professional realization depends on the congruence between personality and environment, which is classified into six types: realistic, intellectual, social, traditional, innovative and artistic. In practice, a pure type is seldom found and there is a hierarchy of preferable environments. In 1984, Keirsey and Bates described four types of temperament: realistic-perceptive (seeks freedom of action), realistic-predicative (dedication, persistence, and giving), intuitiverational (seeks to understand and control the nature), and intuitive feeling (seeks authenticity). According to these authors, there is actually a mix of temperaments, and different occupations may be found in one career.

Sociological Theories The career choice emphasis lays on socioeconomic and cultural determinants. They are decisive factors for the family, the race, the social class, the nationality, the cultural opportunities, and the search for prestige and status. Hollingshead (1949), Miller and Form (1951), Caplow (1962), and Bourdieu (1977) are some representatives of such theories. Economic Theories The possibility of obtaining economic advantages is the major career choice determinant. The supply and demand law would govern the distribution of individuals among different careers. This theory was defended by Smith (1933).

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General Theories According to them, separate determinants could not support a career choice, which would result from the interaction of psychological, economic and sociological elements. The major representatives of such theories are Blau and contributors (apud Ferreti, 1997) and Bohoslavsky (1981); the latter is quoted in the psychodynamics item below because he developed this additional aspect, without ignoring the other ones.

Psychodynamic Vocational Theories

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Freud’s Contributions Although Freud (1973) did not actually elaborate a vocational theory, he has built one of the major pillars of these theories by formulating the concept of sublimation. In 1905, in his classical work Three Essays on the Theory of Sexuality, Freud asserts that sublimation is a process whereby part of infantile sexuality (oral, anal and phallic) is refocused away from its purpose and its energy is then used in artistic or intellectual activities. He also affirms that the reactive formation mechanism1, which begins in the latency period (approximately from 5 years old through puberty) and may be experienced over one’s lifetime, would also relate to uprightness of human character. There is no clear differentiation between both concepts in this text, because here Freud considers reactive formation as a kind of sublimation. Freud’s interest in Leonardo Da Vinci’s geniality led him to publish, in 1910, an article titled Leonardo Da Vinci and a Memory of his Childhood. Here, Freud formulates the hypothesis that most men are capable of deviating part of their sexual energy through sublimation toward a professional activity and then replacing a purpose with nonsexual, and possibly more valuable, ones. In the same text, Freud calls one’s attention to the fact that after three years of age, children go through a sexual investigation period in which they are deeply interested in the origin of children. After this period, a strong sexual repression occurs and three possible destinations for the “investigation drive” appear: • •

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As in sexuality, the desire to know may be limited, thereby limiting free intelligence activities, sometimes for a lifetime, what would typify a neurotic inhibition. Intellectual development is strong enough to resist sexual repression and may interfere therein. After a while, repressed sexual investigation returns from unconsciousness as an investigative obsession that replaces sexual satisfaction. This is a false investigation and no conclusion is attained. The solution is increasingly distant. In the third, more perfect and less frequent, possibility, part of the libido succeeds in escaping from repression and—as from the beginning and by means of sublimation

According to Laplanche and Pontalis (1997) reactive formation is characterized by an attitude or a psychological habit that is opposite to and taken against a repressed desire (shame opposing to exhibitionism, for instance). “It may be a successful defense mechanism or be excessively used and then become an important obsessive character trait”.

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Luiz Roberto Millan

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—increases the investigation drive, which grows intense. Here, there is no obsessive neurosis or intellectual inhibition, which allows the drive to freely act to the intellect’s interest. Up to a certain point, but at a lower degree, the investigation constitutes, also in this case, a replacement for sexual activity. Four years later, in one of his most important works About Narcissism: an Introduction, Freud talks about sublimation again and tries to distinguish it from the ego’s ideal concept introduced in the article. Narcissism is deviated towards another subject, which is seen as a perfect idealized object. Infantile narcissism is, therefore, projected into the one that, in fact, is its own ideal. The sublimation concept describes something that occurs to the drive, while idealization is something that occurs to the subject; and that is why both concepts are totally different. While sublimation is a way to meet the ego’s requirements without resorting to repression, the ego’s ideal, because it relates to moral consciousness, favors repression by continuously comparing the ego to this ideal. Here Freud begins to sketch the superego concept2 formulated in 1923 in his work The Ego and the Id. Over the two subsequent years (1915–1916), Freud produced his Introductory Lectures on Psychoanalysis, whereby he offers an overview of his works published until that date. In lecture XXII, Some Considerations about Development and Regression, he once again approaches the theme of sublimation by asserting that it occurs when sexual drives deny pleasure and procreation and are deviated toward “less selfish” social-oriented activities, which are considered as more valuable ones. In his other lecture The Paths to the Formation of Symptoms, Freud deals with art issues. Artists have strong sublimation capacity and great difficulty to make repressions and overcome their own conflicts. Unlike other persons, artists are able to free their “daytime dreams” (fantasies and imaginative life) from a personal-like nature. This allows them to transform such dreams into a source of enjoyment for others, once human beings have a general tendency to seek comfort in fantasy when they face frustration. Artists are able to embellish their unconscious fantasies until getting a disguise and, then, partially avoid repression. Art is a source of pleasure to most people who, without an artwork, would have no access to such satisfaction. A successful artist, in turn, is recognized, admired and gets what, in their fantasy, they wish most: honor, power, wealth and love, which would never be obtained otherwise. In his Psychoanalysis and the Libido Theory, published in 1923, Freud asserts again that the purpose of a sexual drive is always its discharge, in an aim to get satisfaction, and there is always an object and a purpose. In sublimation, both are replaced, and the original sexual drive finds satisfaction in a non-sexual function, which is more valuable not only from a social but also an ethical viewpoint. In his Psychoanalysis Draft, the last article Freud wrote, in 1938, at 82 years of age, a few days before his death, the sublimation theme is approached again. He states that complete 2

One of the personality instances whose function is similar to an ego’s judge or censor. It relates to moral consciousness, self-observation, and construction of ideal objects (the ego’s ideal). The ego’s ideal would, therefore, be an understructure of the superego. But while the ego submits to the superego for fear of punishment, it does the same in relation to the ego’s ideal for love. Amorous fascination and submission to leaders or hypnotizers would be some examples (Laplanche and Pontalis, 1997).

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sexual organization is only attained in puberty, when the libido is partially incorporated into the sexual function and its coadjuvants and partially repressed or, else, is responsible for the origin of character traits and sublimated, and its purposes are digressed. Therefore, for decades Freud considered sublimation a matter of great importance. He always sought to precisely outline its meaning and origin.

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Melanie Klein’s Contributions Reparation and Kleinian Positions Theory Klein (1974, 1975, 1981, and 1982) says that the complexity of a mature personality may only be understood when the child’s emotional development is understood. Such statement is based on the easily noticeable fact that primitive non-elaborated emotional configurations are experienced again and again, although in different ways, by an individual in his adulthood. According to the author, inside and outside events that occur in the first year of a child’s life are decisive to establish his/her psychological structure, and for this reason they will have an influence upon the individual over his entire lifetime. At birth time, the baby is not capable of intellectually understanding the origin of uncomfortable experiences he/she goes through, which includes birth delivery and hunger, coldness, and belly-ache experiences. The child experiences such discomforts as if they were caused by external hostile objects. When the child is comforted with his/her mother’s breastfeeding, warmth and tenderness, the child feels like receiving care from a good object. Therefore, according to Klein, at birth time an object relation is established. Klein further points out that in the beginning of life sadistic impulses reach their apogee as destructive oral impulses connected with death instinct. These impulses are triggered by frustration experiences, whose intensity is related to inborn characteristics of the baby, who in his/her fantasy attacks the breast and fears to be attacked by the breast with the same intensity, which gives rise to persecutory anxiety. When the baby is rewarded, this anxiety is partially offset and libidinal oral impulses connected with life instinct are activated. Accordingly, in a Manicheist manner, in the baby’s mind the mother’s breast is split into evil breast (the one that frustrates) and good breast (the one that rewards) as if they were two different objects. Aggressive and libidinal impulses are continuously projected to the breast, and then reintrojected, and then projected again and so on. This continuous and complex projection – reintrojection process allows the internalization of an external object and forms an image that is initially distorted by the baby’s fantasy. The primitive ego, therefore, requires integration. While the evil breast is felt as a threatening chaser, the good breast is idealized and seen as something that provides protection and prompt unlimited reward. Idealization then becomes a protection against the persecutory anxiety. In an attempt to avoid persecutory anxiety and frustration, the baby accomplishes, by delusion, the reward of his desires, and in an omnipotent manner creates the fantasy of having control over internal and external objects whose reality is denied. The fantasy of having control over an object is created by a projective identification3 mechanism. While sadistic3

In his article addressed to the Brazilian Psychoanalysis Society of São Paulo, Joseph (1987) points out that the projective identification described by Melanie Klein may have multiple purposes: to get rid of undesired parts

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oral attacks seek to empty the mother of everything that is good and desirable, anal attacks try to fill-in the mother’s body with bad substances and parts of the ego that were projected, in a clear attempt to control, destroy or damage the object, which is then considered as an extension of the ego. The more the child’s inborn aggressive component grows intense, the more his/her persecutory anxiety and avidity and the less his/her frustration endurance will be. However, according to Klein, outside circumstances, such as birth delivery and mother’s care are also fundamental to the satisfactory development of a child. These configurations described above occur during the first three to four months of life. She calls the set of psychological events observed over such period as schizoid-paranoid position. Over the months, provided that a satisfactory relationship with the mother exists, loving feelings (life instinct) addressed to the object overcome destructive ones (death instinct). Persecutory anxiety tends to vanish and split is reduced. The ego is then capable of slowly attaining completeness. Consequently, a composition between loving and destructive feelings, which have become less intense, is now possible, that is, the baby begins to perceive that love and hate are directed to the same object instead of different objects. This perception gives rise to feelings of guilt, depressive anxiety, and then the good object reparation desire. The introjection of the good object, which will be continuously projected and re-introjected, is then intensified. Consequently, the feeling of possessing a good object strengthens and the persecutory anxiety weakens. The ego grows more integrated and vigorous, and establishes a better and more realistic relation with the internal and external world. The child now sees her/his mother as a sole person. Destructive impulses are mitigated and the division between consciousness and unconsciousness, which is now more “porous” and allows intimate perceptions (insights) to occur, vanishes. As the ego grows stronger, it gets the ability to endure anxiety, and the prevalent defense mechanism is now called repression. Melanie Klein called this second development stage as depressive position, which concept should not be confused with the depression described by psychiatry, which Klein named “melancholy”. Slowly, happy experiences help the child to elaborate the depressive position and overcome melancholic feelings, where feelings of guilt and loss predominate. The use of the expression “position” instead of “phase” is not incidental, once over a lifetime an individual oscillates between both positions. The stronger the ego, the longer it remains in the depressive position and the more it oscillates between schizoid-paranoid position and depressive position. In this case, full continuous integration is never possible. The positions theory, which was used by Melanie Klein to understand psychological traits and pathologies found in adults, is briefly described below: •

A schizoid-type patient has had difficulties to overcome a schizo-paranoid position and for this reason he/she mainly uses the defense mechanisms which are typical of

of the self that cause anxiety or pain; to project these parts into the object in order to control it and, therefore, avoid the anxiety of separation; to take possession of the object’s capabilities and subsequently damage them. A child or adult who intensively uses this mechanism seeks to avoid any separation, dependence or admiration feeling, or concomitant sensations of loss, anger or envy. This may result in persecutory anxiety, panic or claustrophobia. Despite being a fantasy, the projective identification may have a powerful effect on the recipient, and since it is associated with an object relation it differentiates itself from the projection.

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this position, what increases his/her lack of confidence in relation to others, fear of persecution and intolerance to frustration. The lack of integration and excessive projection of aggressive parts of the ego weaken the ego, because such parts relate to desirable qualities, such as strength, power and knowledge. Excessive projection of good parts of the ego also produce consequences, since it transforms the other into the ego’s ideal while the individual feels weak, impoverished and dependent. When there is no trust in constructive feelings, the individual resorts to manic (omnipotent) reparation at first, and then to obsessive (repetitive and ineffective) reparation. Suicide would be a manner to destroy the parts of the ego that are identified with evil objects. An individual whose persecutory anxiety is easily activated is incapable of standing criticism, or repairing his own mistakes, or learning from others. He suspects that he is an object of hate, which leads him to have anti-social attitudes, which, in turn, contribute to increase his lack of confidence, thus creating a vicious circle. Psychotic-like persecutory anxieties are mainly responsible for excessive fear of death, once it is experienced as a consequence of inside or outside attacks. In melancholy, the ego is uncertain about its reparation ability, and then reparation is impossible, since it is a “perfect” object that has been broken into pieces. Then distress and a strong feeling of guilt in face of the loss of the object take a stand. Unlike schizophrenic patients, a manic-depressive patient gets into a depressive position but is unable to elaborate it. There is also too much hate towards the object and the incapability of repairing it. In regular mourning conditions, the ego is able to surrender to the pain it experiences in face of a loss, thus experiencing its sorrow. Here, the good internal object is well established, and the individual feels that despite his actual loss the internal and external worlds will continue to exist and the loved object can be preserved internally. Envy is an expression of destructive impulses; its presence is felt from the beginning of a lifetime and has a constitutional basis. It is activated in face of someone who has a valuable and desirable object, followed by an attempt to damage and destroy this object. An envious individual cannot stand others’ well-being or fruition and feels pleased with others’ misfortune. Voracity is the insatiable craving for something given by the object. It is a destructive introjection. Envy, in turn, in addition to attempting to deprive the object, casts malice upon it in an aim to destroy it and is mainly connected with projection. An envious individual cannot stand others’ success and creativity, even though he benefits from them. That is why he is not able to feel gratefulness, which, in turn, derives from the ability to love. There is a short distance between envy, voracity, jealousy and schizo-paranoid position. Destructive criticism is a consequence of envy.

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The need of triumph, hate, and the desire to humiliate and destroy others are primitive envy-related emotions. Unlike envy, jealousy involves at least two persons and relates to the feeling that the object’s love is being threatened or has been stolen by another person. In view of frustration or other unfortunate circumstances, any individual may experience hate and envy. However, when the ego is well integrated, these emotions are transitory and less intense, and arouse less resentment. Those who failed to safely establish a good internal object tend to show weak character, which may be expressed by the craving for power and prestige. Omnipotence, denial and split are reinforced by envy. Idealization, in turn, is not only an attempt of defense against persecution but also against envy, and this may happen when the confusion between good object and bad object arises. Devaluation of the object (it no longer needs to be envied) or the individual himself (which rules out a possibility of rivalry with an important person) is also a defense mechanism against envy. The possession of the objects’ particular qualities, the attempt to stir up others’ envy (by openly showing one’s own success, properties or good luck), and apparent indifference have the same purpose. An excessively ambitious individual, despite all desirable properties, high life status, and prestige this individual might have conquered, is never satisfied. Besides, this individual never allows others to stand out, and assigns secondary roles to them. He would never help the youngest because he fears they might take his place. Furthermore, this individual is not interested in his own work but anything else that might keep his personal prestige. If not excessive, ambition, which relates to primitive voracity, may impel constructive achievements. This is how true leaders are born. Unlike the destructive criticism, the constructive criticism is intended to help others to develop their work. It is only possible when trust in one’s own creativity ends up neutralizing envy. Sometimes it is based on the identification with others or on the activation of maternal or paternal behavior. Devotion to people, defense of a cause, and personal merits are only possible if the good internal object, that is, appropriate elaboration of a depressive position, is satisfactorily structured. The ability to experience satisfaction is closely connected to the ability to love and feel gratitude. Generosity and gratefulness are also closely connected. When the ego is well integrated, generosity does not vanish in face of non-recognition. Otherwise, there would be an exaggerated need for recognition and gratitude, and a sense of spoliation would arise. Empathy and ability to understand others are only possible if the interaction between projection and introjection is balanced, that is, when the depressive position has been elaborated. One’s ability to feel grateful and identify him/herself with someone else leads such an individual to admire others’ character and accomplishments, which makes

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him/her experience a sense of serenity and happiness. Team work may only be successful if its members are able to admire others’ accomplishments. The greater one’s ability to feel gratitude, the greater pleasure and the less resentment, envy and rivalry in relation to others he/she will feel. Generosity is fundamental to creativity. Deeply experienced gratitude activates the desire to reward the kindness received, that is, gratitude is closely linked to generosity. There is a close connection between giving and receiving. Projective and introjective identifications, if not in excess, provide the basis for understanding others and experiencing the sensation of being understood. The satisfactory integration of a good object may strengthen kindness and trust feelings in relation to the object and the ego. Reduced omnipotence, which results from integration, gives rise to certain hopelessness. There is, however, greater discrimination between hate and aggressiveness, acceptance of one’s own limitations and relief of resentments for frustrations he/she experienced in the past and the possibility of experiencing pleasure. Memories of fortunate experiences arouse one’s hope that such experiences will happen again in the future. The feeling of hope is linked to the attenuation of the severity of the superego; a rigid superego would not accept the existence of destructive impulses in itself and in others. One’s ability to be alone and establish a good relationship with others is connected to the establishment of a good internal object and an elaborated depressive position. The ability to feel pleasure is bound to one’s acceptance of being able to enjoy what is possible. Such acceptance neutralizes his/her voracity for inaccessible rewards and resentment for the unavoidable frustration of being unable to get such rewards. Acceptance is linked to tolerance and life hope, since destructive impulses are not expected to outdo the constructive ones. The first incorporated objects constitute the foundation of the primitive superego, which is austere and inflexible. Emotional development leads to tolerance and flexibility. Tolerance does not mean one’s being blind to other’s faults but acknowledging it and, in spite of it, showing his/her ability to love and construct. A mature superego is limited to its duty to manage and restrain destructive impulses. No healthy adult is fully free from guilt feelings, and then his/her desire of reparation is never fully exhausted. Social roles of all kinds originate from this reparatory need.

The Epistemophilic Impulse Chronologically, in 1935, in her article A Contribution to the Psychogenesis of ManicDepressive States, Melanie Klein formulated the depressive position concept, and only in 1946 she described the schizoid-paranoid position in her article Notes on Some Schizoid Mechanisms. However, in 1928, in her writings Early Stages of the Oedipus Conflict, and in 1930, in her article The Importance of Symbol-Formation in the Development of the Ego, she

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would call ones’ attention to the connection between the epistemophilic impulse (desire for knowledge and curiosity) and sadism. There would be a strong desire for possessing the mother’s body contents and knowing what is inside of it. By means of symbolism, during a lifetime, the replacement of the mother’s body with other things, activities, or interests would take a stand. Over her life, Melanie Klein quit the epistemophilic impulse concept and privileged the dynamics between life and death instincts (Segal, 1979).

Persecutory Guilt Grinberg (1963) called our attention to the risk of the depressive position being confused with depression, which is a disorder in the psychiatric nosology. Depression is characterized by narcissistic regression, sadistic superego predominance, and surrender. On the contrary, in the depressive position the subject feels responsible for their own acts, which gives rise to the desire to repair the damage caused to the object or the loss of it added to a strong desire to live propelled by the integration of the ego. According to Grinberg, the depressive position gives rise to depressive guilt, with all the features described by Melanie Klein. Depression, in turn, gives rise to persecutory guilt mixed with schizoid-paranoid components that inflict pain on the subject and lead them to stop their activities. Here, instead of reparation, there is an attempt to pacify the feared chasing object. As long as depressive guilt is connected to the life drive, the persecutory guilt has a close relation with the death drive, and in order to endure it, the subject is often required to resort to primitive defenses, such as dissociation, idealization and negation, or omnipotent or manic pseudo-reparations.

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Bohoslavsky’s Contributions At 27 years of age, Bohoslavsky (1981) wrote his Vocational Guidance—A Clinical Strategy, which most authors deem a classical work. Early death, at 35 years of age, interrupted the career of one of the most brilliant thinkers in the vocational guidance field. In 1977, in an addendum to the Brazilian edition, he wisely stated: In regard to “vocational”, two plans should be pointed out: the plan of problems and the plan of problematic issues. The first relates to people’s difficulty in reaching conscious independent choices – if there are conditions for choosing… A theoretical-problematic issue reaches several sectors of the psychological and extra-psychological field since it involves not only the simple matter of measuring aptitudes and interests and developing test results, but also the most possible free choice made by people about their future life. It is easy to imagine the complexity of problematic issues that such matter involves. They embody both strictly psychological and deep ethical-philosophical-ideological issues. Furthermore, human beings may not be understood in light of a psychological analysis only. Convergent Sociology, Economy, Anthropology, and Pedagogy literature is also required… (pg. 18).

Bohoslavsky calls statistical modality the position of those who believe that, once the aptitudes and interests of an individual are known by tests, the best career choice may be pointed out. According to such conception, socio-cultural reality and careers are static, and

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interests are specific. According to those who use the clinical modality, where the author includes himself, a teenager may only take a career choice after elaborating conflicts and anxieties related to his/her own future, but careers require unspecific and immeasurable potentialities and change over a lifetime. Finding pleasure in studies and career depends on the ties the individual establishes with them, which, in turn, depend on the individual’s personality. Socio-cultural reality and careers are dynamic. And for this reason, despite the importance of being aware of the current reality, no one may foresee the success of a career choice, unless this is understood as a possibility to overcome obstacles with maturity. According to the author, a career choice always relates to others, whether they are real or imaginary; that is, the adolescent does not want a certain career but to be like a person he/she knows, with whom he/she identifies him/herself and who has specific qualities. Because of social values and economic difficulties, work and hobby are generally dissociated, and only a few fortunate individuals do not make such dissociation. For a teenager, his/her professional future is not restricted to what to do but basically to what to be or not to be. During adolescence, the individual defines his occupational identity, a concept formulated by Erikson (1976) and developed by Bohoslavsky (1981): the self-perception, over time, in terms of occupational roles. Occupation is not defined on the basis of what occurs inside or outside an individual; it is an interaction of both of them. Therefore, taking medicine as an example, there is no doctor “in general” and there is no abstract medical occupation. Yet, there is the result of expectations toward such role within a certain historical-social context. The occupational identity is built upon the ego’s ideal (I wanted to be like such-and-such a man/woman…), the identifications with a family group (as a positive or negative reference), the identifications with pairs (teenager society’s culture), and finally the sexual identifications (occupations considered more or less “masculine” or “feminine”). When different identifications are integrated and the individual knows what to do, how to do and in which context, his occupational identity has been acquired. The vocational identity, in turn, relates to the why and what for of the assumption of a certain occupational identity. It relates, therefore, to a psychodynamic understanding of the occupational identity and is obligatorily connected with a theory of personality. Under the psychoanalytic theory, the aforesaid process of sublimation and process of reparation are deemed essential to the formation of such identity. Like Melanie Klein, Bohoslavsky points out that commonly no true reparations but only pseudo-reparations are achieved. In manic reparation, the process is contaminated by the contempt for the good aspects of the object and the triumph in relation to the object (its autonomy is denied); and guilt, instead of being elaborated, is denied. In compulsive reparation there is a persecutory guilt for the destruction of the object, in the individual’s fantasy, in such amplitude that the individual seeks strict and authoritarian reparation, which restricts the object’s autonomy and turns out to be even more damaging to it. In melancholic reparation, the reparation attempt is made through self-destruction. Under this theoretical referential the career chosen would be an external representative of the internal object, which asks for reparation. Finally, Bohoslavsky defines mature choice as that resulting from conflict elaboration, which allows the teenager to identify him/herself with his/her own tastes, interests,

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aspirations, and be acquainted with the exterior world, careers, occupations, etc. An adjusted choice allows the combination of tastes and capabilities with outside opportunities.

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Chapter 4

4. Medical Career Choice

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Literature review shows that several works approach the “medical vocation” issue, which may be divided into some subthemes, such as: the time when medical career choice is made, social profile, doctors and medical school students’ expectations, encouragement and discouragement from friends and relatives, reasons for giving up on a medical career, desirable attributes for doctors, conscious and unconscious motivations for choosing a medical career, personality traits of medical students and doctors, specialty choice, and finally relations between medicine and literature. In order to make a clear and didactic explanation each one of such themes is severally analyzed below.

The Time When Medical Career Choice Is Made, Social Profile and Expectations of Medical Students and Doctors In his study with students from 28 U.S. schools, Yancik (1977) sought to determine the occasion on which they had definitively chosen the medical career. Approximately 10% of such students made their choice before entering high school and 25.9% chose medicine while attending high school. Most students (52.7%) chose medicine while attending the precollege course and 11.4% thereafter. The students who chose surgery specialties made their choice earlier than those who chose other specialties (55% before college). Psychiatrists and general clinical doctors were the last ones to definitively decide that they would follow the medical career. Beedham (1996) showed that in England 62% of students had chosen the medical career before entering college (24% at junior high school and 38% at senior high school). After interviewing 1,044 Mexican medical school students, Fejardo-Dolci (1995) found that 27% had chosen the medical career in childhood, 26% between 14 and 16 years of age, and the others, later. D’Ottavio et al. (1997) remind us that in the 60s, 73% of Argentinean medical students intended to enter medical school before 15 years of age and would make their final decision at 17. The earlier the decision was made the more satisfied students would be with their choice during the medical course of study. In the 90s, 52% of students would think for the first time about following medicine at 16 years of age, and only 17% would do

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so earlier. Most students would make their final decision a short time before the exams. A greater number of students intended to follow other careers (54% x 10%) and were uncertain about their career choice (30% x 5%). In the 60s, 55% of students chose the medical career because of their interest in biology. In the 90s, 30% of students stated that high technology in medicine was the main reason for their choice, and only 16% showed interest in biology. Many youngsters begin the medical course of study without having the slightest idea of medical career demands. Alexander et al. (1992) assert that sometimes, after entering medical school, students feel greatly disillusioned when they become aware that they are doing something they didn’t want to and then abandon the course. They miss opportunities, lose time and money. The authors mention their experience at providing guidance to students who intend to enroll in a medical course: during several weeks, they get in touch with medical terminology and general procedures, bioethics and medical case laws. They are also taught the value of medical secrecy and some qualities such as honesty, ability to feel compassion and to be understanding. Their attention is also called to the fact that medicine requires longtime study before producing professional and personal fruits. In a curious article, Weisse (1993) mentions that Albert Sabin chose medicine, and particularly microbiology, when he was attending dental school and read Paul Kruif’s Microbe Hunters. Such information led the author to carry out a research with 154 US college freshmen and compare the results with his colleagues that graduated 35 years before. The number of female students increased significantly, that is, from 8% to 49%. About 27% of his colleagues were doctors’ children, and such number increased to 34%. The socialeconomic level improved: 51% of his colleagues’ families belonged to low social classes, while 82% of researched students belonged to the middle class. The influence of books on medical career choice was ascertained in 28% of his colleagues and increased to 31% of the current students, which shows that such factor, although usually disregarded, has a strong influence. In his aforesaid study, Fejard-Dolci (1995) found that half of students had a relative engaged in health care activities, and 83% of them were doctors. In Brazil, Pacheco e Silva and Lipszic (1962) studied the socioeconomic profile of the School of Medicine of the University of São Paulo (FMUSP) and the São Paulo School of Medicine of the Federal University of São Paulo (UNIFESP/EPM) students. Among 124 students only twenty were female, being 43% from the Capital city and outskirts, 41% from the countryside, 9% from other states and 7% from other countries. As to social status, only 3% belonged to a high socioeconomic level, 12% were high middle class, 40% were middle class and 45% belonged to lower classes, and 24 students had faced difficulties and privations to enter medical school. Only 36% of them succeeded in entering medical school in the first attempt; 40% of them tried twice, 19% three times and 5% four times. In regard to aspirations and ideals, 65% of students expected to become qualified and good professional doctors; 25% expected to reach a philanthropic and/or an ethical ideal and become true, responsible, conscious and honorable doctors; 27.8% intended to start a family; for 27% what mattered was to gain professional and social prominence, and 5% would like to get good cultural education. According to Rosenthal et al. (1992), the students who choose family medicine have a lower expectation of financial gains by the time they enter medical school, and this is an important predictor of who is going to choose this field. Those who have higher expectations,

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in turn, choose surgery. Kahler and Soule (1991) reported that 90% of students from South Dakota Medical School would like to work in private clinics after they graduated, 18% would like to work as teachers, 3% for the army and 2% in research. Ginzberg and Brann (1980) analyzed the expectations of 150 second-year medical students and found that they were worried about losing their freedom, excessive government control over their profession, salaried employment tendency, decreasing private practice, and red tape. Only one student foresaw a problem-free future. Women showed their concern about needy people’s health, medical education, and human rights. Men, in turn, were more concerned about competition, lack of humanism among doctors, governmental intervention, and financial gains. In his doctorate dissertation, Zaher (1999) asked 293 doctors what changes they would like to make in their lives. About 31% answered that, if possible, they would be more careful with themselves, would have more leisure time, and would devote more time to social matters. 19.45% stated that working-hour reduction would be desirable, 18.77% would like to increase their income, and 17.74% would like to improve their affective, family, and social relationships. Only 7.5% would like to change their career and 5.46% would like to change their specialty, while 18.43% said they were fully satisfied and did not intend to make changes in their lives.

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Encouragements and Discouragements Toward Medical Career Choice Third parties’ influence is outstanding to career choice. For this reason, some authors studied how future medical students are encouraged or discouraged from following the medical career. According to Baird (1975), students are generally encouraged by their family to become doctors, but the lack of perspectives on midterm financial gains would be a matter of concern. Imperato and Nayeri (1991) carried out a study with 314 New York College freshmen. About 68% of them had been discouraged from following a medical career—43% by doctors and 40% by friends and neighbors. Their parents were the ones who most encouraged them (58%), followed by friends and neighbors (47%). The alleged reasons for discouragement were long training years (55%), high medical malpractice insurance costs (50%), excessive government regulation (43%), the doctors’ way of life (40%), income reduction (39%), high tuition costs (26%), and serious illness risk (22%). No differences between genders were found. The authors call our attention to the fact that according to surveys carried out during the 70s only 25% of students had been discouraged from following medicine, and discouragement was predominant amongst female students (19% x 8%).

Reasons for Giving Up on a Medical Career In order to understand the decline in medical course enrollment during the 80s in the US, Colquitt and Killian (1991) carried out a survey to find the reasons that led many students to

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decide against a medical career in spite of having, at first, an interest in medicine. In 1986, the main reasons given were: the possibility of satisfying their interest in the sciences through other careers (38%); high tuition costs (28%); doctors’ lack of freedom (25%); being discouraged by doctors to follow medicine (22%); and finally because they would have to walk a long way to become a doctor (19%). A new survey was carried out two years later. At this time, the astonishing percentage of 48.2% of students who decided not to follow medicine said that they had been discouraged by doctors! The strong competition amongst medical students led 12.4% of applicants to decide against medicine, and financial interests led 34.8% to choose other careers. Also astonishing was the fact that 22.9% of applicants were told that they would have greater possibilities to help people in other careers. On a supplemental basis, the authors compared the opinions of those who had chosen medicine and those who had not in relation to positive and negative aspects of the medical practice. They found that those who gave up on a medical career were more pessimistic in relation to a successful career in medicine and more concerned with time-consuming duties that would interfere in their private lives. Finally, the authors call our attention to the fact that by the end of the 80s, the proportion of applicants to medical course vacancies was 1.6% applicants per vacancy, the lowest proportion in the last 55 years. Chuck (1996) shows that premedical course students fear the long duration of the medical studies and residency (56%), high tuition costs (52%), professional stress (51%), fear of making mistakes (46%), physical stress (43%), high medical malpractice insurance costs (40%), risks of contracting diseases (27%), and administrative problems (20%). All such factors were considered by the students as reasons for discouraging them from following a medical career. In a literature review, Beedham (1996) asks why young English doctors abandon the medical career. The English doctors’ satisfaction with their jobs dropped from 81% to 44% last year; 20% regretted their career choice, and one third of them would like to abandon the career, if possible. Work-related stress is the main reason for dissatisfaction. Women complain particularly about the overlapping of professional activities with home-care responsibilities. In England, 13.7% of students abandon the medical course of study. The reasons for abandoning the course are: long training years (55%), high medical malpractice insurance costs (50%), excessive governmental regulation (43%), lifestyle (40%), income decrease (39%), high tuition costs (26%), and the risk of serious illness (22%). No significant differences were found between genders.

Doctors’ Attributes More than 2,400 years ago, Hippocrates listed in his The Law the necessary attributes for those who wished to embrace the medical profession (Brunini, 1998) as: a natural disposition, a disposition for study, early initiation, perseverance, love for the work, and available time. First of all, natural talent is required, because if nature opposes everything will be in vain. When, however, it indicates the path and direction towards the best achievements, learning about the art is a pleasure. The student should, in turn, try to assimilate such learning through reflection, and become, as from the beginning, a pupil on an appropriate place to education,

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so that the acquirements that are being rooted will produce suitable abundant fruits (page 165).

In Hippocrates’ aphorisms it is read that a physician must have good observation capacity without any kind of prejudice, must be honest, altruist, idealist, humble, should seek to learn in all circumstances and never seduce his patients. First of all, he can do no harm to his patient and should always trust in the healing power of nature. In China, during the 7th century, Souen Ssen-mo describes the attributes that in his opinion are indispensable for those who choose medicine as a career (Carvalho Lopes, 1970, p. 74):

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It is not enough to study Confucius or Tao’s literature to become a good physician. Those who have not read some Buddhist books do not know what Kindness, Compassion and joy of Resignation mean. They will not be able to conquer patients by means of piety and sympathy, or create a proper environment to assist them and relieve their pain without thinking about their lineage, their fortune, their age, their beauty, their intelligence, their identity as Chinese, Barbarian, friend, or enemy; nor shall they be able to treat patients with equality, just like they would do with their dearest friends.

Psychoanalyst Zimmerman (1992) reminds us that the art of medicine is very old and was practiced by wizards, shamans, and priests. The medical science, in turn, originated in the 19th century and since the beginning it has suffered the influence of its mystical predecessors. How many times is a failure attributed to “God’s will”? For how long a successful doctor keeps his charisma regardless of the results of his approach? Historically, mysticism, primitivism and ignorance have always been together. Together with the medical knowledge evolution a horizontal doctor-patient relationship arises, and then the physician steps down from his pedestal. For the author, it doesn’t matter what kind of personality a physician may have but certain attributes are indispensable to the practice of medicine, such as intuition, empathy, continence, communication, and ability to get depressed. Intuition relates to experience and cognitive processes. Empathy relates to affective capacity and allows the doctor to put himself in the other’s place. Continence allows the doctor to get in touch with his patients’ anguishes, death events, and existential crises and have the chance to tranquilize them. Furthermore, it allows the doctor to stand his own anguishes, doubts and the “not to know”. The ability to get depressed (in the Kleinian sense) allows discernment, individuation, autonomy, reflection, and creativity. Finally, the ability to communicate relates to knowing how to listen to the patient, not to get his mind full of pre-concepts, not to morally judge patients, and how to deal with painful true facts, as well as, of course, how to use an easily understandable language. In his classical book Psychosomatic Conception: A Current View, Mello Filho (1979) reminds us that becoming ill is a challenge to omnipotent conceptions present in the unconsciousness of all individuals. On the other hand, omnipotence aspects may feature a lifestyle or career choice, including medicine. He suggests that by facing extreme conditions, such as the risk of infection, death events and serious illnesses in their day-to-day life, doctors may need a certain amount of omnipotence, which is a personality trait that is usually criticized in doctors.

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According to Lacaz (1997) the true doctor embraces his/her career for vocation. The core of the medical profession is to serve patients and never make use of them. The patient must feel that the doctor is able to give something; without such ability there is no practice of medicine. Furthermore, the doctor must understand the language of pain, anguish, fear, hopelessness, and suffering in order to talk directly to his/her patient’s soul, which is only possible if the doctor “has all sensitivity that a human being can shelter” (page 234). A genuine medical vocation is quite similar to love, since its purpose is to serve others, and not to be served by them, says Marañon (1935). It is, therefore, far away from passion, where exclusivity to the beloved object is sought, and it is often platonic. Young people usually confuse vocation with the search for good remuneration, recognition and glory. Where there is vocation there is a sense of sacrifice and specific aptitudes, which are not easily identified but should not be confused with examination grades, since a good devoted medical student may have no medical vocation and vice-versa. According to the author, vocation can be developed from life experience. Family doctor Blasco (1997) points out that medicine is both science and art, that is, a scientific art:

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To be a doctor is, first of all, to balance the forces that legitimate such assignment, which are, in fact, the reason for the existence of medicine. It is the proportional harmony between science and art, in equivalent weights. The abnormalities that hyper-atrophy an aspect to the detriment of another not only result in doctor’s low professional qualification, but they also reach the doctor’s own core and destroy it. A bad doctor is not the final proceeds of this unbalance, because what he practices is no longer medicine. He might be a kind of “mechanic of people” or a “witchdoctor”, but never a physician (page 29).

According to the author, it is difficult to talk about the medical art, and even more difficult to teach it. Over his/her life, the doctor should continuously seek to get close to the ideal doctor’s profile, whose features include good cultural education, critical sense in relation to new scientific acquirements, prudence, keenness, solidarity, dedication, an open mind to changes, professional humanity, lack of vanity or dogmatism, and professional ethics. A good doctor should also refrain from transforming medicine into business. He/she must have actual interest in his/her patients, keep secrecy, know how to listen to his/her patients and be attentive to them, explain an illness to a patient in an understandable language, and, finally, he/she should have the ability to exchange place with his/her patient. These attributes have been mentioned in the literature. An interesting study was carried out by Price et al. (1971) with the cooperation of 372 doctors, who suggested a long list of desirable attributes a doctor should have to be considered a good professional. Subsequently, the list was revised and modified by other physicians, residents, patients, students, medicine students, managers and other professionals. A final list containing 116 qualities, 87 of them being deemed positive and desirable, and 29 negative and undesirable, was then obtained. The list was subsequently formatted as a scale and delivered to 1,604 persons from different fields. Among the 87 desirable qualities, in order of importance, the first five were:

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Good clinical discernment (ability to make appropriate decisions about the patients’ care). Bring him/herself up-to-date in his/her own field. Have knowledge and ability to carefully study his/her patients’ conditions and reach safe conclusions about diagnosis, treatment and related issues. Provide prompt assistance to patients as appropriate. Ability to accurately examine each patient so to produce an accurate diagnosis and suggest appropriate treatment.

Among the 29 undesirable qualities, in order of importance, the first five were: • • • • •

Negligence in dealing with patients. Frequently incurring medical errors. Dishonesty. Alcoholism. Drug addiction.

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The authors point out that the opinions from very different populations such as lawyers, hippies, physicians, students, among others, were slightly different. More than ten years after Price and collaborators’ work was published, Sade et al. (1985) used their scale again in order to answer the following question: “Do the best medical students become the best doctors?” In addition to the original scale, the desirable attributes of a doctor that can hardly be taught in a medical school were investigated. The questionnaire was answered by 84 teachers from the School of Medicine of South Carolina University. The first five desirable attributes, in order of importance, were: • • • • •

Good clinical discernment (ability to make appropriate decisions about the patients’ care). Ability to accurately examine each patient so to produce an accurate diagnosis and suggest appropriate treatment. To bring him/herself up-to-date in his/her own medical field. To be emotionally stable. Good doctor-patient relationship.

The first five desirable attributes that cannot be taught, in order of importance and obtained by an index, were: • • • • •

To be emotionally stable. To be a person with unquestionable integrity and principles. To be straightforward and intellectually honest. To be naturally powerful and enthusiastic. To be very intelligent, brilliant, mentally fast and diligent.

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At the end of the study, the authors conclude that maybe in the future it will be possible to select medical students not only for their cognitive qualities. Anyway, the comparison between both studies calls our attention to the fact that in the second study two non-cognitive attributes among the first five desirable attributes are mentioned, which evidences a greater concern with the human aspect of medicine, maybe because such aspects have deteriorated significantly over the years. In the first class attended by medical students at Cornell University, their teacher Rogers (1993) said that society sees today’s doctors as less altruist and less generous than they were in the past. They are seen as cold individuals who are more concerned with technology than human conditions. Rogers further says that unfortunately such a perception is somehow true and asks his pupils to never forget that humanitarianism is a powerful therapeutic tool. According to him, the union of compassion, concern with others, and competence is outstanding to the medical profession. Finally, Whitehouse (1997) asserts that it is easy to accept that in addition to cognitive attributes other future doctors’ features are desirable, including, but not limited to tolerance, social responsibility, critical sense, compassion, flexibility, ability to stand uncertainty, and empathy. Therefore, some medical schools have introduced an interview to filter a few students who have good academic potential but lack the other attributes.

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Conscious Motivations for Choosing Medicine as a Career Several articles approach the conscious choice for a medical career. Among them, research, considerations and depositions show that the issue has been holding the academic society’s interest for decades. In order to investigate the reasons for choosing a medical career, Baird (1975) carried out a survey of 521 medical students and concluded that they had been mostly driven by the desire to help others, work with people, and conquer independence and security. Ginzberg and Brann (1980), in turn, have found that the major motivations for choosing a medical career are the desire to perform good deeds, the intellectual challenges, and the fascination with the profession. The search for prestige and good financial gains is less but significantly mentioned. In another survey, Kahler and Soule (1991) conclude that the desire to serve other human beings and carry out a difficult assignment made 70% of the freshmen from South Dakota Medical School choose a medical career. The others were motivated by status and financial reward (Kahler and Soule, 1991). In a study with 304 students from the Medical School of Wisconsin College, Siverston (1988) concluded that 36.5% had chosen the career because of their desire to help others or their scientific interest; 19% desired to work in a health-related field; 4.3% mentioned that a certain disease they had in the past had influenced them; 2.6% mentioned their interest in the missionary aspects of the career, and 2% had been influenced by the death of a friend or relative. Family influences were significant: 17.4% had a physician father and 63% had a relative working in the health care field. About 11% of the students said they had been influenced by doctors that took care of their families.

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Concerned with students’ decreasing interest in medicine during the 70s and 80s in the USA, Sadeghi-Nejad and Marquardt (1992) remind us that the desire to serve humankind has been the main motivation for choosing the medical career in all times. Other motivations are mentioned in their literature review, such as illness in the student’s family or contracted by the student him/herself during childhood. The influence of financial gains is decreasing, the period in which physicians most prospered financially began after World War II and decreased over the last decades. For a long time, physicians had prestige and played the role as friends and advisors. With the creation of specialties and sub-specialties, however, the profession has been fragmented and physicians are not seen as idealized subjects as they were in the past. Consequently, while medical science has gained respect and prestige with its developments, the opposite has occurred with doctors. Over several years, those who chose medicine were attracted by the independence offered by the career. Physicians were free: they developed their best skills and adjusted their work to their individual needs, lifestyle and personalities. Nowadays, free doctors have almost disappeared. The fear of being sued for medical error has led them to act defensively and have their profession controlled by insurance companies. The authors suggest that experienced doctors transmit to their pupils the idea that, despite all problems, medicine is still an excellent career that combines science, personal satisfaction and intellectual challenges. In an interview with 1,780 premedical course students, Barondess and Glaser (1993) compared the motivations of those who had chosen medicine with those who had chosen other careers (second percentage): • • • • • • •

Satisfaction at work (96% x 90%) Providing aid to people (83% x 56%) Job challenges (80% x 61%) Being deeply acquainted with human beings (60% x 47%) Caring for the less fortunate (59% x 62%) Free time for leisure, family and friends (44% x 65%) Guaranteed financial gains (41% x 62%).

The authors concluded that medical course applicants are mostly motivated by altruism and satisfaction to work in a field they like. With his provocative article titled “Do you want your child to become a doctor?” Parmley (1993) approaches the US medicine crisis at the end of the 20th century and points out that despite all matters, some intrinsic values of the medical career remain unchanged. He also points out the most attractive reasons for choosing medicine as a profession, such as: the chance to help people and receive their gratefulness and trust in exchange; the possibility of learning with each patient, who is unique; the intellectual stimulus provided by medical specialties’ fast progress; the opportunity to teach young learners; and finally being acquainted with other devoted doctors. In their survey with 1,044 Mexican medical school students, Fejardo-Dolci (1995) found that personal satisfaction was the main reason for choosing medicine (58%). Chuck (1996) reported that 71% premedical course students had been influenced by a doctor they were acquainted with while choosing the medical career.

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It should be pointed out that after a substantial reduction in medical course applications in the US, the number of applications beat the record in 1993 and 1994. According to Steinbrook (1994), career choice is a very personal decision, which involves financial gains, intellectual challenges, prestige, job opportunities, stability, place of work, and free time for leisure and family. Further, the choice for medicine embodies the desire to provide aid to people. The generous care for the well-being of others is inherent to the medical profession, and is also a doctors’ privilege. Medicine is featured as an altruistist career, and before the financial benefits, altruism should be the greatest incentive for those who intend to embrace medicine as a career. Such comments were made for an article written by Weeks et al. (1994) where the income yielded by workers from different fields is compared. Attorneys and specialist doctors earn the highest incomes, followed by dentists and executives. Generalist physicians (primary care providers) come last. It should be advisable, then, to create incentives to those who are interested in this field. In his interesting statement, Leung (1996) a fourth-year medicine student at Western Ontario University says that approximately 90% of freshmen enter medical school with the intention of becoming vascular surgeons or neurosurgeons, which are prestigious medical specialties, but such percentage decreases significantly over the course. According to him, the medical career is becoming less and less attractive from the financial viewpoint; and the lifestyle it offers is not nice. At the same time, a few show sympathy for doctors or their profession. Notwithstanding, he affirms that it is a privilege to have a career that enhances his life in so many aspects and makes him feel emotionally and intellectually alive. There is nothing more rewarding than hearing the first baby’s cry or seeing a sweet smile on a mother’s face as she takes her newly born child in her arms for the first time. All daily frustrations resulting from financial difficulties vanish when a patient says a simple “thank you” after surgery. That is why after being asked if he would leave medicine, his answer was a laconic “no”. By observing the increasing number of medical school applicants despite doctors’ overall dissatisfaction as to work conditions, Chuck (1996) asks: Do US premedical course students know what they are applying for? In order to answer this question, the author sent out a questionnaire that was answered by 84 premedical course students with average age about 22 years, being 57% women, 43% men, 87% single, 10% married and 4% divorced. The influence of physicians who played a model role to 71% of such students and parents of 67% of them were important for their career choice. As to professional fulfillment, 98% answered that they would heal and provide aid to people; 95% of them said that work would satisfy them intellectually; 83% said they would gain prestige; 73% said that work could be nice; and 84% answered that they would be satisfied with their gains. In relation to this subject matter, two publications stand out. Pacheco e Silva and Lipszic (1962) carried out a survey with 124 fourth-year students from the School of Medicine of the University of São Paulo (FMUSP) and the São Paulo School of Medicine of the Federal University of São Paulo (UNIFESP/EPM) in order to investigate their conscious motivations for choosing medicine as a career. Philanthropic ideals (desire to help and be useful to others) led 40% of the students to choose medicine; the nobility of the profession (admiration for the medical career since childhood and the possibility of practicing it as a priesthood) ranked second, with 37% of answers; third parties’ example influenced 21% of the students;

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scientific curiosity and interest in medicine-related disciplines came next with 19.5% of the answers; title, prestige and respect motivated 10.6% of students; the possibility of material gains and social ascendancy appeared in 10.4% of the answers; personal or relatives’ suffering made 9.6% of the students choose medicine; and finally 5.6% made their choice by exclusion. In his doctoral dissertation, Zaher (1999) analyzed a questionnaire sent out to 293 physicians from several Brazilian States for the purpose of investigating conscious motivations for choosing medicine as a profession. The answers were organized into groups and categories. The first group was comprised of individuals that had chosen the medical career because of third parties’ influence: family doctors (15.69%) and doctor friends (5.12%). The second group members had chosen medicine either in childhood (12.28%) or because they had had a serious disease (0.68%). The third group was named “personal motivations and ties with others” and subdivided into three subgroups. The first subgroup, with 33.10% of the answers, included “vocation”, admiration for beauty, dignity and art of work, idealism, and personal accomplishment. The second subgroup, with 41.29% of the answers, included enjoying the career or something related to it coupled with the desire to provide aid to, heal, and take care of other human beings and engage in social activities. The third subgroup, with 8.19% of answers, was related to social status, labor market and socioeconomic ascension. Swiss psychoanalyst Schneider (1991), already mentioned above, reminds us that becoming a doctor is one of the most common conscious desires among children and teenagers, but it seldom comes true. The desire to hold power over others and make money, although present, is not usually admitted. There is, in general, great interest in art, literature and the humanistic approach to medical problems. The humanistic interest is as important to the medical identity genesis as is altruism, which could explain the existence of so many writer doctors. The balance among scientific, humanistic and altruist dimensions is absolutely essential to the practice of medicine; that is why a selection to enter a medical school which considers only the scientific performance tends to be inaccurate. Social environment also influences a medical career choice. Historically, several dynasties of physicians were mainly built upon their identification with doctor fathers and, more recently, doctor mothers. Such identification is partial and may consciously facilitate a decision-making process, but above all this is an unconscious process. The same is often observed in other careers. Sometimes, parents want their children to become doctors or wanted to be doctors themselves, which leads young people to take another’s desire as their own, without even noticing it. In his unpublished autobiography, English psychiatrist and pediatrician Winnicott (1988), as mentioned by Outeiral (1988), says that when he was a three-year-old little boy he destroyed the nose of his sister’s doll with a cricket bat and felt deeply relieved when his father restored the doll’s face with wax. When he was sixteen he fractured his clavicle playing rugby and at that moment he desired to become a doctor: “I could not picture that for the rest of my life I would depend on doctors… so I decided to be a doctor myself” (page 11). In one of his several writings about the history of medicine, Scliar (1998) says that a Brazilian doctor’s offspring Oswaldo Cruz was not a brilliant medical student and was never attracted to the clinical practice. However, he loved microbiology and became one of the

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most important names in the history of Brazilian medicine. He also introduced public health and scientific investigation in Brazil. His “love at first sight” is described with his own words: As from the day we were allowed to admire the breathtaking view we get by bringing our eyes close to the ocular tube of a microscope on which plate a preparation lies; as from the very moment we saw with the aid of such a wonderful device the several living creatures that populate a single drop of water; and were taught to handle a microscope, the idea that our intellectual efforts would be focused on education and specialization in a microscope-based science thereafter has taken root in our soul (page 13).

The author mentions that Darwin, who in 1859 revolutionized genetics with his The Origin of Species, was a doctor’s son, and to satisfy his father’s desire he entered the medical course at Edinburgh College. Soon after that, however, he abandoned the course because he got sick while attending a surgery (Scliar, 1996). Great histologist Gaspar Vianna was excellent in mathematics and had a natural vocation to become an engineer. However, following his elder brother’s advice, he decided to study medicine (Falcão, 1998). Renowned scientist and founder of the Brazilian Association for Science Advancement (SBPC), Vianna was disappointed with the medical course and considered the idea of studying physics. During the medical course, he shared his time between seeing patients and reading. He then published his book Porcelain Dolls. The influence of two teachers, whom he worked with and admired, put an end to the embryonic phase of his career, which became a success thereafter (Doctors, 1998).

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Unconscious Motivations for Choosing Medicine as a Career While several articles approach the conscious motivations for choosing a medical career, the sole indexed article by Krakowski (1973) draws our attention to unconscious factors. If well elaborated, infantile instinctive aspects and conflicts may lead the doctor to acquire satisfactory traits, but if not, they may give rise to serious difficulties. Psychological identification mechanisms, narcissism, omnipotence, curiosity and sadism should be then explored. −

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The unconscious identification with one’s doctor father is useful to Oedipus complex elaboration and allows the individual to follow his father’s path. It may, however, be an attempt to surpass his father and be preferred by his mother, or an attempt to deny his experiences of fear of his father by identifying himself with the aggressor. An omniscient and omnipotent doctor, besides being unaware of his/her professional limitations, is narcissistic and vain to the point of placing his/her personal success before his/her patients’ needs. Children’s curiosity about the genitals may contribute in part to a medical career choice. A satisfactory resolution of this curiosity by means of sublimation may give

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rise to scientific curiosity; otherwise the doctor may face difficulties and inhibitions while exploring his/her patient’s emotional and sexual life. Compassion and desire to heal other beings may originate from a sense of guilt triggered by aggressive and destructive impulses. Genuine compassion is possible when identification with the suffering subject exists. If sublimation and reparation processes are defective, the doctor will be unable to control his/her aggressive impulses and his/her patients may become victims of such impulses. Sometimes this aggressiveness turns back to the doctor him/herself, who, due to strong guilt feelings, sacrifice him/herself to the point of becoming masochist or defensively passive. A counter-phobic attitude toward death is an important motivation for choosing the medical profession. Several defense mechanisms are involved in a patient’s death, including coldness, scientific indifference, keeping away from beloved ones, denial, projection and choice of a specialty as protection. By stating that they would rather be “scientists”, some diagnosis field researchers or physicians may in fact be trying to avoid contact with their patients’ death. Those who cannot stand old-aged ones’ deterioration may choose pediatrics. A geriatrician may not endure a child’s suffering, while a gynecologist may choose to deal with young women because they rarely die. Surgeons usually seek fast results and truly strive against death; and clinical doctors are, in general, emotionally involved with their patients.

There are, however, some non-indexed books, dissertations and articles that approach the unconscious motivations for choosing the medical profession. In 1926, using Freud’s theory and children’s games model as a basis, psychoanalyst Simmel writes an article titled The Doctor-Game, Illness and the Profession of Medicine published in the International Journal of Psychoanalysis. It suggests that the medical career would be a way to satisfy primitive desires related to the principle of pleasure, now socially accepted and consistent with the principle of reality. Further, it would be a way to access usually inaccessible issues, such as difference between genders, nudity, feces and urine manipulation. By playing doctor, children choose a game which is in agreement with the most stimulated erogenous zones at the time and strong emerging drives. Aggressive and sadistic tendencies could be represented by the surgeon role, for instance. The appearance of the medical profession was a cultural advancement because the wizard that practiced sorcery directly expressed his sadistic drives, while in relation to physicians the same drives appear in a sublimated manner, inhibited by their identification with patients. According to Schneider (1991), the “motivation” concept presupposes high-level consciousness. Unconscious aspects, in turn, show up imperfectly and misshapen as ghosts, reveries, dreams and symptoms. And they are not as clear as the choice-supporting reasons may be. They are thought-affection networks that reveal desires, fears, anguishes, and defenses through a language that requires interpretation. True medical identity consists of both the recognition that the society grants to the knowledge and abilities of doctors, and their own awareness of such qualities coupled with psycho-affective and psychodynamic potentialities, which are gradually developed and allow them to play their role as doctors, think about and be aware of their limitations. At a certain point of their career, doctors will feel pleased with their work and may tell others – and themselves – that they are doctors, and

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then establish a good relationship with their patients. Those who lack proper medical identity feel ill at ease in their activities and insecure in relation to patients. Because of their deep professional identity, doctors have not the same mobility to change occupation as other professionals that engage in activities that privilege techniques, objects and finance instead of human beings do. Historically, physicians have suffered violent attacks to their identity, whether in an attempt to reduce its importance or value, or else to reduce it to a mere commercial activity. Until today these attacks have slightly changed the doctors’ identity, which seems to be a stable sound structure. The commercial conception of medicine in the USA, however, is a risk to the doctors’ identity, which can disappear in face of financial values, such as profits. Scientific knowledge, although indispensable, is not a particularity of the medical profession. In medicine, the relationship with other beings, imperfect life quality, death, physical and psychological pain, the body and its vicissitudes, are particularities. The knowledge doctors acquire from their patients, and from their own experiences, becomes the main nutritive sap of their identity. According to the author, the most frequently described unconscious motivations for choosing the medical profession are: control, the search for reparation in relation to others and themselves, reactive formation, power to destroy death as a narcissistic expression, voyeurism, powerful superego, a hardly attainable ego ideal, and altruistic tendency. Masochism in doctors is frequently mentioned but their unconscious sadism has been poorly analyzed. In his interesting article titled About the unconscious delusion of goodness and aid, Ahumada (1982) describes subjects whose own need for emotional care is fulfilled by taking care of others. They enthusiastically devote themselves to other beings and for this reason they are socially admired and respected and considered to be trustworthy, generous and vivacious people. Their devotion to others is so intense that such individuals not only live for others but fail to live their own lives as well. And any attempt to rescue their own life strongly competes with a dedication-based mental structure and tends to fail. In terms of unconscious functioning, such individuals make certain dissociation from their personality traits that require care, love, comprehension and relief, which are refocused to others. They are usually nice and fun because they project boredom and depression onto others. This personality dissociation is necessary because of their fantasy that surviving would not be possible if dissociated aspects were present, and generosity would be the counterpart of their own selves’ unexhausted need to help. This could be the origin of the compassion that is so present in such individuals, whether consciously or not, who are strongly attracted to actual or imaginary unfortunate ones. When dissociation is successful and reaches its highest degree it leads to excessive selfconfidence, which is reinforced by social acceptance; and the individual is seen and sees himself as a mature strong secure person. This belief, in fact, hides their incapacity to stand physical pain, or feel true pleasure or inner emptiness. Despite their apparent modesty, their excessive self-confidence gets close to arrogance. The author names such configuration as kindness and aid delusion, which would be present in childhood and, to some extent, in adulthood as well, particularly when capabilities and actual successful attainments support such delusion. Delusional superiority hides, in fact, a delusional inferiority. By quoting

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Liberman (1980), the author states that some activities are appropriate to expel non-valuable aspects of the self. This mechanism could explain some medical, paramedical, scientific and academic vocation events. The term “altruist” would not fit in such events, the term “pseudoaltruist” would be more appropriate. The term “selfless” is appropriate to illustrate these events and is literally accurate: it is devotion without self, where devotion takes the place of the self. According to Ahumada (1982), genuine kindness may only be achieved by the portion of the personality that has reached a depressive position. Here, the necessities of others are in resonance with the necessities of the self, which are within the personality itself. Consequently, forbearance, genuine affective resonance and the ability to get moved arise. The acts of “giving” and “receiving” move apart from feelings of omnipotence and unworthiness respectively. Like other aforesaid authors, Wender (1965) considers vocation, from the psychoanalytical viewpoint, as an expression of reparation. It originates from the elaboration of anxieties that correspond to a depressive position. However, it is possible that a certain profession cannot fulfill all reparatory and vocational tendencies, and then the remaining drives would require supplemental sublimations. This could be understood as a consequence of the special connection with partial aspects of the internal object, which now expresses its own voice in regard to the vocation issue. It also explains vocational changes over a lifetime, hobbies and parallel activities. The author mentions the example of musician, philosopher and writer Albert Schwertzer who at the age of 40 began to study medicine, probably because of remaining reparatory drives that could not be totally fulfilled. Likewise Bohoslavsky (1981), Wender describes manic-compulsive-melancholic pseudoreparations that often respond for apparently unexplainable medical failures. Subsequently, he defines what he considers to be true reparation: when the internal reparatory impulse moves, in a similar symbol formation process, to an external object, which then symbolizes the internal object. In the medical profession, symbol and symbolized object are so close that it is very hard to distinguish one from the other. Reality and fantasy mingle once the doctor actually takes care of an ill patient, just like he/she did in childhood when he/she sought to repair the body of the primary object (his/her mother) attacked in his/her fantasy. It is difficult for any doctor to treat a relative because it threatens his/her whole symbolic construction. In these cases, the great challenge is to make a useful psychological dissociation between patient and internal objects. Since the process of studying has no reparatory value, medical students face a dramatic psychological situation when they enter college, because the whole possibility of reparation that has driven them toward the career choice is postponed to a far distant fantastic future. They feel impotent or begin to make use of any of the aforesaid pseudo-reparations. In the beginning of the medical course, besides lacking the proper tools for performing their professional duties, the students lack inner maturity to play a doctor’s role. In their unconsciousness, at that moment, they may be doctors or wizard’s apprentices. Their archaic internal world and schizophrenic-paranoid configuration, with a highly persecutory content, is then reactivated. If pseudo-reparatory mechanisms remain over the doctor’s professional life they not only will disturb the doctor’s internal balance but also adversely affect their relationship with

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patients and professional performance. The doctor may not accept a patient’s death, partial improvements, or treatment discontinuance. Their inability to accept science restraints may lead them to perform reparation-driven acts, which translate into unnecessary medical visits, refusal to receive medical fees, etc. In melancholic reparation, by identifying him/herself with a patient the doctor begins to show hypochondriac symptoms. Only after achieving emotional maturity as a result of depressive position elaboration, the doctor will be able to accept that he/she has only relieving, preventive, and eventually healing, means at hand. The entanglement between reparation and total recovery of a subject, which at the utmost point consists of providing resurrection, is then untangled. Finally, Wender points out that phobic structure is another common aspect of a physician’s personality. This aspect often emerges by the time the student chooses his/her specialty and unconsciously avoids conflicting specialty areas. As an example, the author mentions organicist psychiatrists who deny any psychodynamic aspect in mentally disturbed patients and, paradoxically, choose to take care of them by a counter-phobic mechanism. Body phobia, in turn, may lead the doctor to prematurely choose psychiatry or psychoanalysis, while others choose research. Further, there is the “pure” investigator who is driven by curiosity, loves science for what it is, and is not worried about repairing his object whatsoever. According to psychiatrist and psychoanalyst Hoirisch (1976), by choosing a medical career the individual seeks defense against death, which is “symbolized in infirmity and personified in his patients” (page 3). The doctor now represents health, youth and life and will not give up on this role, even in his/her family or social environment. But because he/she is, in fact, human, mortal and fallible like anybody else, he/she often feels guilty. Guilt is an inherent feeling in the medical profession. By accepting an idealized role, the physician identifies him/herself with the divine mythic character Asclepius and is convinced that he/she has magical power, which not only will save his/her patients but also eventually prevent his/her own death. By approaching the same subject matter, Simon (1971) introduces the “Thanatological complex” concept, which is present in an idealized being and the several magic acts attributed thereto. The object of such acts is the omnipotent triumph over death, the immortality, which is a universal desire. Over time witchdoctors, divinities and priests have played this “thanatological” role. Among several motivations for choosing the medical profession, the thanatological complex stands out. In the beginning of the course it becomes evident through the desire to discover the etiology of and cure for fatal diseases. This fantasy is somewhat understandable and necessary for scientific initiatives, and will be gradually confronted with the reality. However, if a doctor or student fully identifies him/herself with such omnipotent being, he/she will be taking commitments that cannot be fulfilled, and failure is the only possible result. Persecutory guilt with a consequent tendency to selfpunishment then arises. Consequently, the doctor is subject to an inner pressure that originates from narcissism and an outside millenary pressure resulting from society’s expectation toward his/her performance. A close contact with medical students from the Psychological Counseling Group of the School of Medicine of the University of São Paulo (GRAPAL) provided some subsidies for Millan et al. suggesting that unconscious elements are in fact true determinants of a career

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choice. Anguish and impotence before death would give rise to the fantasy that by saving other people’s lives the doctor would be able to save his/her own life. This fantasy would be a consequence of the doctor’s limited ability to accept limitations, which could give rise to an omnipotent behavior and a mechanism of denial against human reality. If predominant, this mechanism may cause serious problems in the future: doctors with difficulty in dealing with both their own mistakes and patients that do not respond to treatment as expected; and doctors that exaggeratedly devote themselves to patients and become careless with their own lives. Furthermore, painful situations they went through in the past, particularly in childhood, and identification with relatives and friends might affect their career choice. A few years later, De Marco (1999), another Grapal team member, states that because of methodological obstacles it is very hard to draw up a psychological profile that takes the vocation-for-a-certain-profession aspect into account. However, a daily contact with medical students in interviews and psychotherapy groups and sessions would place the observer in a privileged position, since there is no direct concern with the vocational issue approach. Knowledge spontaneously and naturally comes out. According to the author, curiosity (how we are, how we work, how we become aware of ourselves and life in general) coupled with generosity constitute the core of the medical vocation, which, in practice, shows up as empathy and a consequent desire to help other beings. The true guiding principles for taking care of patients are rooted in the students’ personality. However, vocation may be developed over the professional life through their relationship with teachers, colleagues and patients. Two other authors should be mentioned: Rocco (1992) reminds us that medical students often begin the course without being fully aware of their career choice. This choice may result from their own or their family’s idealization, or their desire to perpetuate family medical tradition, or their vocation for serving other beings, or else in their search for healing power or exerting control over people. Blaya (1972) points out that medical choice is first of all a matter of desire, whether conscious or not, to get more acquirements and be able to better take care of one’s own illness. In the statement transcribed below, Freud (1979) describes with genuine straightforwardness how he chose the medical career and the vicissitudes he faced until finding his true vocation, psychoanalysis (Jones, 1979, pages 62 and 63). Although we lived under very restricted circumstances, my father insisted that my career choice should be taken in consonance with my own inclination. At that time and over my lifetime I have never had special preference for the medical career. I was led by curiosity and such curiosity was more directed toward human concerns than to the route of natural objects; I had not even learned the importance of observation as one of the best means to fulfill such capability. My premature acquaintanceship with the Bible (shortly before I learned reading) had, as I found out later, a lasting effect on the direction of my interests. Under the powerful influence of a schoolmate’s friendship, a boy older than me who would become a well-known politician some years later, I got in touch with my desire to study Law like him and engage in social activities. Concomitantly, Darwin’s theories strongly attracted me because they amplified the world’s hopes; and after listening to a beautiful Goethe’s essay about Nature, in an out-loud voice reading session during a popular lecture addressed by Professor Carl Brühl shortly before I left school, I decided to become a medical student. After 41 years of medical practice, my self-knowledge tells me that I have never been a real doctor in the actual sense ascribed to the word. I became a doctor after having been compelled to digress from my initial purpose; and the glorious triumph of my life lays on the

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fact that after walking a long sinuous path I have found my way back to my first purposes. My inborn sadistic aptitude was not too strong; therefore, I felt no need to develop it from its unfolding. In fact, I never “played doctor”; my infantile curiosity, of course, chose other paths. In my youth, I felt an uncontrolled necessity to understand the enigmas of the world we live in, and maybe even pay my own contribution to solve them. It seemed to me that the most appropriate step to achieve that goal was to apply to a medical school; but then I devoted myself to – unsuccessful – experiences in the field of Zoology and Chemistry until engaging, at last, under the influence of Brücke – the greatest authority who influenced me more than anything else in my entire life – in Physiology, in spite of such discipline being, at that time, basically restricted to Histology. Despite my lack of interest in anything related to Medicine, I had already taken all medical career exams when a teacher whom I deeply respected advised me that in view of my financial conditions I would not be allowed to choose a theoretical career. Therefore, I left nervous system histology and embraced neuropathology, and then, stimulated by new influences, my interests were focused on neuroses. It comes to my mind, however, that my lack of true medical temperament might have caused some damage to my patients. It is not advantageous to patients that quite great emotional emphasis is put on their doctors’ therapeutic concerns. Better aid is provided to patients if the doctor performs his tasks as coldly and consistently as possible.

Personality Characteristics of Medical Students and Doctors Before approaching the “medical student’s personality” issue, we should discuss the concept of personality and the tools commonly used in such assessment.

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Concept of Personality and Assessment Tools The concept of personality is one of the issues that most arouses interest in psychology, and is considered to be one of the most complex and polemical matters in this field (Allport, 1961). It is also one of the most abstract concepts known, and no definition alone should be deemed correct. Derived from Latin “persona”, the word meant the theater mask used by the Greeks at first, and subsequently by the Romans, in order to hide the actor’s identity. In Cicero’s writings (106–43 BC), probably soon after the word persona had been created, four meanings were ascribed to it: • • • •

The way someone appears to others but not whom he/she actually is; A role someone plays in life; A set of personal abilities that qualify the individual for his job; and Synonym of distinction and dignity.

Several definitions of personality derived from these four meanings, as used in daily activities, art, philosophy, law, religion, sociology and psychology. Allport (1961) defines personality as a “dynamic organization of the psychophysical systems existing inside an individual that determine his adjustments to the environment” (page 65).

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In his study about personality and career choice, Ramos da Silva (1992) says that the essence of personality may be defined as “the most singular fraction of the self—its originality”. He points out that several studies demonstrate that personality traits influence vocational behavior, but advises that this parallelism does not correspond to a single association process. Argentine psychoanalyst Bleger (1989) reminds us that for a long time the scientific objectivism turned aside any interest in the study of personality, but the return of such interest places psychology and human beings together again. According to him, personality is characterized as a totality system with a certain stability-unit-integration organization, which shows up in each and every behavior of an individual. There is no personality without behavior and there is no behavior without personality. And there is no human being expression that is not connected to their personality. Personality comprises nature, temperament and strength of mind. Nature represents somatic and physical characteristics, which are more basic and steadfast and depend basically on hereditary features. Nevertheless, it is not free from environmental and psychological factors’ influence. Temperament consists of smooth dominant affective features (instinct and vital feelings). For some, its origin is fully hereditary, and for others it may be influenced by the environment during the first years of life. Strength of mind, in turn, is conditioned by acquired factors and represents both the psychosocial side of the personality and the most personal features of its structure (Fernandez, 1979; Bleger, 1989). The US Psychiatry Association (DSM IV, 1994) defines personality traits as the persistent patterns existing in the way an individual perceives, is connected with and thinks about others, the environment, and himself, displayed on a broad brand of social and personal contexts. The World Health Organization (CID 10, 1992) defines personality as a range of behavioral conditions and patterns that are typical of an individual and tend to be persistent and express such individual’s lifestyle and relationships with other people and him. There are several methods for investigating personality: direct behavior observation, biography, projective tests [Rorschach, Thematic Apperception Test (TAT), Personality Projection in the Drawing of the Human Figure, Children’s Thematic Apperception Test (CAT), among others] and quantitative tests [Minnesota Multiphase Personality Inventory (MMPI), Sixteen Personality Factor test (16 PF), Cloninger’s Temperament and Character Inventory (TPQ), California Personality Inventory (CPI), Myers Briggs test, and Factorial Personality Inventory (IFP)]. Interview is one of the most commonly used methods for investigating a personality. Historically, according to Nunes (1993), the term interview means “a face-to-face meeting between individuals for a formal conference, at a certain time”. Initially used in journalism, the interview turned out to be an important tool for other professionals, such as philosophers, physicians, lawyers, psychologists, sociologists, nurses, among others. In Psychiatry, from the beginning of the 20th century, with Kraepelin (1907), through today, it is considered the main assessment tool that provides knowledge about a patient. Further, according to Nunes (1993), a psychological interview can be classified pursuant to the following criteria: theoretical focus, purpose and structure. As to theoretical focus, it can be classified into:

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•

•

Psychoanalytical Perspective: interview is focused on the interviewee’s psychodynamics, intra-psychical structure, object relations and interpersonal functioning. Humanistic-Existential Perspective: it usually does not aim at a diagnosis. Emphasis is laid on interviewee’s current experiences, decision-making attitudes and awareness thereof. Phenomenological Perspective: interviewer seeks to get rid of his/her presuppositions so as to create conditions for the interviewee’s just being him/herself. The interviewer must stay open-minded and in the present time in order to formulate hypotheses and understand the case.

As to purpose, it can be classified into the following: • • • • •

Diagnostic: aims at establishing patient’s diagnosis and prognosis and proper therapeutic procedures. Psychotherapeutic: employs psychological intervention strategies in order to elucidate patient’s difficulties and help him/her solve his/her problems. Indication: the purpose is to indicate a treatment to the patient which will not be conducted by the interviewer. Discharge: by the time of discharge, it helps the doctor to analyze the benefits obtained from treatment and suggests post-discharge strategies. Research: aims to investigate several matters of clinical interest and should always be carried out upon the patient’s consent.

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As to structure, it can be classified into: •

• •

Unstructured: when the interviewer is interested in the interviewee’s spontaneous speech and follows the natural flow of interviewee’s ideas. It allows broader and deeper investigation about personality. Structured: it is standardized and requires specific information. It allows systematic data comparison. Semi-structured or semi-directed: interviewer is free to make questions and organize their sequence. Such kind of interview allows systematic data comparison without limiting the use of the material that arises spontaneously in the course of the interview.

The Personality of Medical Students and Doctors By studying the personality of 521 medical students, Baird (1975) concluded that they had a conservative profile, little interest in free time and traveling, great interest in job and studies, and were more satisfied with the medical course than students from other courses. “What has happened to medical students’ creativity?” was the interesting question that led GOUGH (1976) to investigate the creativity in 284 freshmen and compare it with that of

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professions and students from other fields. Surprisingly, medical students surpassed significantly architects, psychology students and mathematicians. Scientists were surpassed too, but there was no significant statistical difference. The group segment analyzed showed that the most creative students were those who had chosen psychiatry, followed by internal medicine students. Curiously, the group of students who abandoned the course ranked third. Pediatricians and obstetricians were the least creative. In a study carried out in the Medical School of the University of Nebraska, Hoellerich (1982) found that freshmen were idealistic and concerned with humanitarian issues. During the course, feelings of compassion and idealism gradually decreased and were replaced by cynicism and money-making concerns. Krakowski (1982) studied the personality profile of one hundred doctors from different specialties and was astonished at the fact that all of them considered themselves as compulsive personality individuals. Most group members— predominantly male (90%)—considered themselves to be active, independent individuals with the ability to endure pain and tiredness. Zeldow et al. (1985) investigated the presence of masculine and feminine traits in 106 medical freshmen, being 72 male and 34 female. They used the Personal Attributes Questionnaire (PAQ), which is disposed into scales containing socially desirable items for both genders: independence, diligence and competitiveness, which are considered male features, and gentleness, warmth and concern about others’ feelings, which are seen as female features. Students of both genders with high masculinity levels showed psychological wellbeing, low-level depression, greater self-esteem and self-confidence, feeling of personal control over life benefits, greater capacity for pleasure and interpersonal relationships when compared to low-level masculinity ones. High-level femininity ones showed more depression and anxiety symptoms, higher neurotic symptoms, greater concern with others’ opinion, more humanistic attitudes toward patients and greater optimism as to reciprocity to their feelings. According to the authors, androgynous individuals, that is, those with high masculinity and femininity levels are particularly qualified to play satisfactorily their role as doctors: they are self-confident and competitive enough to endure academic stress, have humanistic attitudes and are concerned with interpersonal relationships before a curriculum that puts a priority on basic sciences and medical technology. They concluded that a greater number of female doctors would not be enough to humanize medicine, but the presence of high-level feminine attributes among doctors would do so. Many scales have been created to evaluate the aspects of personality that differ the most. Merril et al. (1993) conducted an interesting research to identify the level of Machiavellism existing among 167 freshmen and 823 fourth-year students from US medical schools. After a statistical study, five useful phrases to the investigation were selected: “the best way to deal with people is to tell them what they want to hear”; “when you ask a favor you’d better give strong instead of true reasons for that”; “it is difficult to go on without taking a shortcut route here and there”; “never tell anyone the true reason for something you have done, unless it is useful to do so”; and finally “it is a wise decision to adulate prominent people”. The authors concluded that 15% of students reached high levels on Machiavelli’s scale. Authoritarianism, intolerance to ambiguity, excessive confidence in high-tech medicine and belief that their responses and success depend basically on external factors were some prevailing outcomes in male students. No differences between freshmen and fourth-year

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students were found. The highest scores were attained by anesthesiologists, followed by radiologists and those who had chosen surgical sub-specialties and pathology. Family medicine and internal medicine got the lowest scores. The same authors tried to identify authoritarianism traits in the personality of medical students from five US colleges. They found strong authoritarianism traits in 19% of 1,886 fourth-year predominantly male students. During the course these traits increased mainly among women. The greater the intolerance to ambiguity and Machiavellism, the greater the presence of authoritarian traits; and such students would see more negatively patients suffering from chronic pain, alcoholism, drug addiction or hypochondria. In regard to specialty choice, the most authoritarian students chose pathology, followed by anesthesia, surgery subspecialties, radiology and surgery. The less authoritarian ones chose psychiatry, followed by gynecology-obstetrics, pediatrics, general clinical practice, and family medicine. The authors assert that teachers are partially responsible for the creation of an inhumane environment for medical services provision and close their article with a strong text:

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If medical schools expect to meet the primary care demands of a nation, what are students doing at medical schools? The answer is quite simple: we are more interested in our applicants’ grades and scientific performance than values and interests. We feel more comfortable with objective numbers discharged by computers than subjective assessments resulting from interviews and personal judgment – and maybe this is another indication of the authoritarian traits existing in all of us (Merril et al., 1995, page 90)4.

In his literature review, Martins (1990) points out some personality traits of medical students and doctors. In general, medical students are brilliant, extremely competitive—with obsessive-compulsive characteristics—and perfectionists. They repress and do not share their feelings, always seek security, tend to emphasize intellectual aspects to the detriment of emotional aspects, seek precision, and try to help others—many times to the detriment of their own needs. They also avoid asking for help, and their altruism is often a consequence of the reactive formation mechanism mentioned above. The same author observed that resident doctors feel deeply hurt before hostile or demanding patients. Giving bad news to a patient’s family, assisting terminal patients, and fear of contracting infections were also mentioned. The fear of making mistakes, time pressure, fatigue, night duty, lack of guidance and excessive control from supervisors were the main stressful reasons mentioned. They would also give rise to rage, revolt, helplessness, and a sense of being explored and disrespected. Stress tends to decrease over the years. The group of male clinical students and of female surgery students had greater adjustment difficulties. Recently, some theses and dissertations produced in our field have approached the doctor’s personality issue. Manente (1992) carried out a study with resident doctors at the São Paulo Hospital (São Paulo School of Medicine of the Federal University of São Paulo (UNIFESP)) and pointed out the importance of children’s play for the origin of the interest in medicine and the reparation mechanism for the medical vocation. Zaher (1999) used Trinca’s projective 4

Free translation made by the author.

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drawing-and-story procedure in five doctors. Rationalization was a defense mechanism often used by them. In general, these doctors avoided talking about their conflicts, anguishes, and feelings deemed negative such as sadness, rage and loneliness. Issues like job, victories, efforts, power and strength were emphasized. Hard self-criticism impaired the symbolization, and the necessity of being accepted by their families, society and themselves was ascertained in all cases. Narcissistic and omnipotent aspects were significant in two cases. In general, they mentioned their intention to protect and support their families and their need to be protected and supported likewise. By studying the attitude of doctors toward their own illness and comparing it with that of lawyers and engineers, Meleiro (1999) concluded that doctors are less motivated to change their routine, feel more anxious and irritated, and are unconcerned about being good patients. They often disapprove of their doctors’ conduct and are doubtful about their prescription, and are concerned with side effects. They have difficulty in accepting medical care as something valuable to their health improvement as well. Before being admitted to a hospital, they tried self-medication and delayed asking for medical assistance, which probably were the reasons for a greater percentage of deaths in the first 48 hours in comparison with the group of engineers and lawyers. With the aim of elucidating the relations between personality traits and medical, clinical or surgical specialty choice, Bellodi (1999) carried out an investigation using the Rorschach test and structured interview on medical residents at Hospital das Clínicas of the School of Medicine of the University of São Paulo (HC - FMUSP). The mean age computed was very low (25) and the great majority of them were single, Catholic and had medical family lineage (70% general clinic practitioners and 63% surgeons). Most of them came from the Brazilian Southeast Region and capital cities, and 60% of the clinical doctors and 73% of the surgeons came from the São Paulo Capital City. Male gender predominance was observed among the surgeons, and most of them came from public medical schools, particularly the FMUSP. Most clinical doctors, in turn, came from private medical schools. Surgeons showed a tendency toward early choice of specialty, sometimes before entering medical school and, like the clinical doctors, showed satisfaction with the choice made. Clinical doctors explained that they had chosen this specialty because it would allow comprehensive care and close contact with patients—because continuous care would be required—and also because they were fond of intellectual activities. Some of them consider clinical doctors “the true doctors” and clinical practice as “the medicine” itself. The surgeons answered that they like manual activities, practical and objective interventions, and young patients with acute problems. For some of them, the surgeon is a “complete doctor” because surgery “is beyond clinical practice”. The Rorschach test showed that clinical doctors work slowly when they face ambiguous problems, are more attentive to details, hypercritical, and tend to opposition, reflection and imagination. They have difficulty dealing with anxiety, are strongly concerned with and interested in other human beings, have intellectual ambitions and a tendency to abstraction. They tend to rely on personal experiences and evade the environment. They show difficulty in expressing their sexuality and tend to project aggressiveness onto the environment. Surgeons, in turn, work fast, at a level close to impulsivity, while facing ambiguous situations. They show lower opposition to the environment, tend toward reasoning and

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formalism, hardly control their ambitions, are strongly interested in and concerned with other human beings, have less empathy, and project less aggressiveness than clinical doctors. Both groups are similar as to the following aspects: they are self-critical and judge their own behavior; they fear being inadequate; they have difficulty in dealing with less structured situations; they are theoretical and emphasize all-over aspects; they are rational and critic in relation to the environment; and they are affectionate, emotive and subject to stimulus. They also tend to control their affects but seldom do it rationally, which lead them to have immature relationships with others. Anguish and tendency to associate aggressiveness to the representation of human beings, with unreal omnipotence features, are also present. They have non-stereotyped thoughts, a unitary vitalized real picture of themselves, and are adjusted to collective values and thinking. The study of gender shows that men and women of the same specialty bear closer resemblance to each other than men and women who choose different specialties. Additionally, there are bigger differences between male clinical doctors and surgeons than among women in these specialties. As to the motivations for choosing the specialty, female clinical doctors show grater interest in interpersonal relationship while female surgeons are more interested in medical practice results. Further, in relation to personality traits, male clinical doctors show greater creativity and project more aggressiveness than women of the same specialty. Andrade (2000) sent out the Defense Style Questionnaire (DSQ) to medical, law and engineering students by the time they entered college for the purpose of detecting the defense mechanisms used by each group. Among medical students, pseudo-altruism, sublimation, reactive formation and annulment were remarkable traits found. Among law students, projection, acting, regression, denial, and scission were prominent. No significant differences were found by comparing both genders. In the same work, the author sent out a questionnaire to medical course residents and freshmen and concluded that good temper, reactive formation, refusal to aid (hypochondria) and annulment prevailed among the first ones. Here a difference between genders was found: good temper prevailed among men and regression and seclusion were more significant among women. The author also concluded that law students have more primitive and immature psychological functioning, low reflection capacity, and a Manicheist view of life. Engineering students, in turn, have difficulty dealing with their own feelings and affects. In regard to medical students, the author suggests that the desire to help and take care of others could be associated with guilt or reparation needs, and their prevailing defenses characterize an obsessive-compulsive character. Finally, the author points out that residents do not show more mature defenses than applicants do, which could demonstrate a slow maturing process, maybe caused by stress. In his doctoral dissertation, Ignarra (2002) distributed questionnaires among 162 medical students from two medical schools in the city of São Paulo, Brazil, in order to investigate the students’ social representation about the medical profession. He found that career choice had generally been made in childhood and students had been strongly influenced by their families, and often identified themselves with doctors they had been acquainted with. The author also concluded that students are aware of the sacrifices imposed by a medical career

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and believe that good relationship with patients, ability to save lives and altruism are the best qualities a doctor may have. Self-experimentation was often fatal, but in the history of medicine it was not unusual, many times involving doubts or controversies about the origin of infectious diseases, and vaccines and drugs’ efficacy (Scliar, 1996). • • • • • • • •

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•

John Hunter inoculated himself with discharge from a patient who had gonorrhea; In 1892 Max Von Pettenkofer swallowed a bacteria culture to prove that Robert Kock was wrong and almost died because of this; Waldemar Haffkine (1892) tested a vaccine on himself; Hilary Kapronski (1954) did the same with an anti-rabies vaccine; Anton Storck (1760) drank water hemlock because he believed in its healing power; Friedrich Seturner extracted morphine from opium and used the drug for the first time; Jan Purtuinje ingested digitalis. Despite his teachers’ opposition but with the assistance of a classmate, in 1885 medical student Daniel Currión inoculated himself with a patient’s wart for the purpose to solve a controversy and died soon after; Surprisingly, in 1937 bacteriologist Max Kuczinsky-Godard repeated the experiment and escaped alive.

These attitudes reveal important personality traits in doctors and medical students such as omnipotence, narcissism and inconsistent search for notoriety and recognition. There is no accurate information about a doctor’s personality and their psychodynamic professional functioning, affirms Schneider (1991). In an aim to partially clarify these issues, Schneider made an extensive bibliographic review enriched with his personal experience. First of all, he makes an important clear distinction between authority and power concepts. The first results from knowledge and competence—every doctor is, or should be, a person with authority. Political, moral or legal power, in turn, is granted by third parties. In primitive medicine, wizards and shamans were seen as individuals with divine or diabolical power, and because of scientific developments such power has increasingly lost its strength. Notwithstanding, until today, by fearing illness and death, many patients grant great powers to their doctors and believe that by doing so they will be protected. The doctor then feels powerful and omnipotent, which may induce him/her to errors in diagnosis and conduct. Therefore, it is essential that doctors dissociate authority from power; otherwise they will not be able to provide for their patients’ safety and gain their confidence. Doctors have in general obsessive personality traits, which may give rise to an expectation that their patients should strictly follow their prescriptions irrespective of the number of appointments or guidance adequacy. Balint (1961) called this attitude an “apostolic function of a doctor”: One particularly important aspect of function is that doctors are required to prove to their patients, to the whole world, and most of all to themselves that they are good, kind, trustworthy and helpful doctors. However, we know that this is an idealized image. We have particular temperaments and idiosyncrasies, and that is why sometimes we are not as kind and

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understanding as we would like to be. Our knowledge is incomplete and fragmented and despite our best intentions there are some patients that we cannot help, because there are and there will always be some incurable conditions5 (Balint, 1961, page 79).

Schneider (1991) says that medicine is by definition an altruist profession. First of all, doctors feel pleased for having helped, taken care of, or occasionally cured a patient. The pleasure of compensation should come second, which does not always happen. An important amount of interest in human beings is required. When this interest is present, a friendly doctor-patient relationship naturally arises. At the same time, it is desirable that doctors keep secrecy and be neutral, and also avoid erotic and aggressive attitudes in their relationships with patients. These requirements have been stated in the Hippocratic Oath and although they seem tenuous today they are still valid for most physicians. Discretion, neutrality, altruism, friendship toward patients, authority, suspicion in relation to power and omnipotence, and abnegation are attributes that all physicians should long for but will hardly get because they are ordinary people, have doubts and imperfections. Because they don’t correspond to this ideal sometimes, doctors are attacked and defend themselves with a shield of cynicism, provocative jokes, affective indifference, and even coldness. Those who fully sacrifice themselves for their career become strict and intolerant in face of the “required altruism”. Accordingly, a “basic inadequacy” between the requirements made to doctors and what they can actually do arises. It is worthwhile mentioning that these attributes that the society and doctors themselves require precede the emergence of Christianity, which has always valued altruism so much. In the contemporary world, however, there is the risk of the marketing of medicine making doctors gradually lose their typical attributes and replace them with those of businessmen, which would adversely affect their patients to the extent that medical regulations were replaced with unethical economic rules. Doctors’ responses to failure will depend on their psychological resources—and may range from indifference to good mood, from patient’s accusation to self accusation, from anxiety to depression or drug addition. Reparation mechanisms are also used such as being increasingly cautious, improving knowledge and employing more constructive and nicer concepts. But they are restricted by the fact that medicine is not an exact or natural science; in fact, medicine is an art that lives with uncertain and unpredictable issues. Such issues may be reduced in the future with the development of science, but they will never be eliminated. Schneider (1991) further says that free doctors are faithful to their patients, not only because of financial interests, but most of all because of their need to know that their care has been recognized, and such recognition reassures their value. In general, doctors devote certain affection to their teachers and concomitantly seek freedom and independence. Their indignation at the world’s injustice led them to create international entities such as the wellknown “Doctors without Borders”. Sometimes, doctors are seduced by politics and take highly important offices. The already mentioned doctors’ obsessivity appears in their fear of making mistakes and forgetting important scientific information, and a certain stiffness. However, in general, it is not featured as a pathological obsessive-compulsive disorder. Sometimes, it is considered to 5

Free translation from the author.

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be a personality trait that is inherent in doctors and somehow necessary. In general, it results in excessive working, difficulty in enjoying free-time, and conflicts between their dedication to patients and family, which often triggers a feeling of guilt for demanding so many sacrifices from their families. Despite their taste for circumspection, discretion and reserve, doctors share two features with actors: exhibitionism and voyeurism. The first relates to the pleasure of showing their value at the office, hospital and classroom. The classical example of a clinical chief seeing a patient at the hospital with a court of doctors following him illustrates this. Voyeurism relates to the pleasure to look at, examine and touch patients. A doctor who feels at ease with him/herself may have such qualities, which should not be confused with perversions that have the same name. Within the sadomasochist universe, physicians are often closer to masochism, in spite of some authors considering exactly the opposite. A masochistic tendency becomes evident when a doctor devotes him/herself completely to patients, becomes exasperated with their demands and has no time left for other activities. Such attitudes relate, as we have seen before, to obsessivity and a strictly tenacious superego. In general, doctors are very critical in relation to themselves and easily feel guilty. Their attitude towards money is ambivalent, since they are divided between the desire to make good money and the moral injunction of helping others. Moral rules also require doctors to have non-erotic and non-sexual relationships with patients, which under certain conditions may give rise to frustrations, which, if poorly managed, may lead to some faults. However, patients are often in health conditions that make their bodies seem anything but beautiful and seductive, and in order to touch them, the doctor has to overcome other feelings such as aversion and rejection. By dealing with death, suffering and psychological and physical pain, the doctor may have his/her own balance disturbed. To defend and protect themselves from and against feelings that might disturb their psychological functioning, doctors many times deny the importance of a situation and its afflictive repercussions through apparent indifference or coldness. Another defense mechanism used is to make dramas look like banal events, thus transforming them into their opposite so that only their funny side remains. Sometimes, doctors respond to these dramas with omnipotence, and feel so secure that they are able to deny them. Finally, Schneider (1991) points out that in general there is no big difference in doctors when they are inside or outside their workplace, but their defense mechanisms tend to be less active when they are not working. This is understandable because their personality has been built up since childhood, and it is one of the factors that influences their professional choice.

Choosing a Specialty In a survey carried out with 395 students from a Medical School in Alicante, Spain, Miralles et al. (1987) found that 55.69% had definitively chosen their specialty in the first year and no difference as to gender or age was found in regard to such aspect. Only 11.13%

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of students were doctors’ offspring but most of them (70.45%) affirmed that this fact had great influence on their career choice. In a literature review, Henry et al. (1992) listed the variables existing in a medical specialty choice: factors such as gender; parents’ occupation; family, school and social history; nationality and marital status ranked first. In second place were personality and attitude before patients, death, team work, ability to make decisions and solve problems. In third place were education-system-related factors, such as boarding school, performance at school, selection system, specialties’ image. In fourth place were career-related factors, such as financial compensation, prestige and the possibility of owning a private clinic. Such factors were followed by work conditions, including at hospitals, working hours and free time for family. And finally, the intrinsic factors of every specialty, such as contact with patients, research, intellectual fulfillment, etc. A prospective study carried out at Northwestern University, in Chicago, shows that approximately 22% of students had already chosen their specialty by the time they entered medical school, while 45% had an idea of what specialty they would choose. When personality traits were compared between those who had changed their minds up to two times and those who did so several times during the course, the latter tended to be less anxious. Unlike other studies that showed that those who had chosen surgery and psychiatry by the time they entered medical school were the most resolute ones, this study showed that such early definition had been made by those who chose family medicine and internal medicine (Zeldow et al., 1992). A similar survey made in the Medical School of South Dakota showed that 45% of students intended to choose family medicine, 22% were in doubt, 11% intended to choose surgery, 9% internal medicine, 5% gynecology-obstetrics; and anesthesiology, orthopedics, neurology and emergencies had been chosen by 2% each. The authors point out the importance of altruism in a medical career choice (Kahler and Soule, 1991). In a study with 102 students attending the last year of the medical school of the University of California, Osborn (1993) concluded that 89% had chosen their specialty in order to help people and because of intellectual challenges. Only 20% considered financial aspects as something important, and most of them did not choose primary assistance (internal medicine, family medicine and pediatrics). Male students were less interested in such fields and preferred high technology and academic fields. By the time female students chose a specialty they were more concerned with the number of working hours. In order to determine the factors that influence a specialty choice, Kassebaum and Szenas (1994) distributed to 8,128 senior students a 36-factor scale. The most significant factor was the type of patient, followed by personality coherence, chance of changing people’s lives, interest in helping others, intellectual content of the field, diagnosis challenges. Prestige, desire to become an authority and financial compensation were less significant. Free time and time flexibility to be with their families had moderate importance.

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Medicine and Literature In 1965, Doctor Eurico Branco Ribeiro founded the Brazilian Society of Writing Physicians (SOBRAMES) inspired in the Societé Mondiale des Écrivains Médecins headquartered in France, which gathers writing physicians from several countries. Beglionini (1999), president of SOBRAMES, states that the act of writing is inspired by a medical career because it allows close contact with human beings’ suffering, cheerfulness, hope and disappointment. According to Scliar (1996), the doctor-patient relationship is inevitably permeated by emotion. On the other hand, both anamnesis and scientific medical texts lack emotion: there is no doubt, indignation, fright, terror, incredulity, reticence or anxiety on the part of doctors or patients. He suggests, then, that this is the reason for many doctors resorting to literature as a way to get close to human beings. There are several examples of doctor-writers, such as: Pedro Nava, Guimarães Rosa, Cyro Martins, Varella, Lobo Antunes, Rabelais, Tchekhov, Céline, Williams, among many others. All such authors could be trying to break the barrier between humanistic and scientific cultures. Additionally, several times the authors used doctor characters. Among several examples, the work of Turgueniev (1818–1883), The District Doctor, which reports the drama of a physician who is going to lose a patient with whom he is in love, should be mentioned. In his legendary The Doctor and the Monster Stevenson (1850–1894) tells the story of a physician, Dr. Jekyll, who discovers in his experiments a substance that transforms him into the killing monster Mr. Hyde. Thus, the author places altruism, which theoretically characterizes the medical profession, against destructibility, which at some level is present in all human beings. In his theater play A physician’s dilemma premiered in London in 1906, Bernard Shaw strongly criticized the commercialization of medicine and the defense of public health assistance nationalization: “By turning physicians into traders we compel them to learn trade tricks; that is why the year’s fashion includes treatments, surgeries and certain drugs” (Scliar, 1996). In 1937, Cronin published The Citadel, a work that influenced youngsters worldwide to choose medicine because of its idealistic and anti-mercantilist position. A year later, Brazilian author Érico Veríssimo wrote his novel Look at the Lilies of the Field where he strongly criticizes the commercialization of medicine. The author believed that a medical career should be embraced by one who has a true vocation. He considered medicine an act of love. In 1939, in the preface of his book Namoros com a Medicina Brazilian author Mário de Andrade wrote about his desire to become a doctor and a certain frustration for not having accomplished it because he “lacked vocation” (Scliar, 1996, page 259).

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Chapter 5

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5. The School of Medicine at São Paulo University (Faculdade De Medicina Da Universidade De São Paulo—FMUSP)

FMUSP building close to its inauguration in the beginning of the 1930s; which forms part of the collection of the History Museum Carlos da Silva Lacaz – FMUSP.

A Brief History of FMUSP The first attempt to found a medical school in the State of São Paulo, Brazil, came in 1891 when a law creating “the Academy of Medicine, Surgery and Pharmacy” was enacted. The project was not successful at first. Two decades later, in December 1912, the São Paulo Medicine and Surgery School was created in compliance with a law enacted by President

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Rodrigues Alves. Doctor Arnaldo Vieira de Carvalho, who was formerly a clinical director of the São Paulo Holy House and enjoyed great social prestige in the medical class, was appointed as its principal. He then appointed administrative employees and teachers. The first provisional headquarters was installed at Alvares Penteado Trade School and some classes were held at Polytechnic School. In the beginning of 1913, the first admission tests were taken by 180 students. Twenty of them were bachelors in Law, nine had graduated in Sciences and Literature, twenty-two had graduated from Normal School, and two from Polytechnic School. Teachers Emílio Brumpt from the School of Medicine of Paris, Alfonso Bovero, from the College of Turim, and Lambert Mayer from the School of Nancy, were the first foreign teachers to be hired. In 1914, the School offered the course in a building located at Rua Brigadeiro Tobias, and in 1915 the São Paulo Holy House made two infirmaries available to students. The São Paulo Maternity and Juqueri Hospital did the same. In 1924, the Oscar Freire Institute, which nowadays belongs to the medical school, offered Anatomy courses (Lacaz, 2000). In 1931, with the aid of the Rockefeller Foundation, the School gained its own building, where it remains established today. Before donating the necessary funds, the Foundation sent a committee to Brazil and such committee created several requirements; one of them required that the number of students should be limited. Education should follow US standards, as specified by Flexner, who in 1908 commended a clear distinction between basic and clinical education, emphasized the teacher’s role as the main source of knowledge, didactic independence of each department, and early specialization of students. Teachers should devote their study not only to education but to research as well (Bittar and Marcondes, 1994; Boulos, 1994; Lacaz, 2000). A curious fact was that of the 180 students who took the preliminary course only 28 graduated six years later, in 1918. In the first year of the medical course, 58 truant students lost the year and 52 were suspended for indiscipline. Among the remaining seventy students, 34 failed the first-year examination and eight abandoned the school during the course. The suspended students picked a quarrel with the chemistry and medical physics teacher because he had reproved 85% of the students. Such quarrel was only resolved by a last minute court decision, when Judge Rui Barbosa rendered his decision in favor of the teacher. Only two women graduated in 1918—Odete Nora de Azevedo and Dilia Ferras Fávero— and both got married to classmates. Pursuant to Figures 1 and 2 below, in the four subsequent years, no women graduated. In 1923, only one woman graduated, and in the six subsequent years, only men graduated from the medical school. In 1969, for the first time women represented 20% of the medical students; and in 1992 they reached 48% of the graduates, a record that has not been beaten until today. In 2000, 113 students enrolled in the first-year medical course; 65% were male and 35% female. Other outstanding information is that a few years ago none of the FMUSP teacher’s offices were taken by women. In 2000, of forty-six teachers, only four were women (Medical School Foundation, 2001).

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160 140 120 100 80 60 40 20 0 Figure 1. FMUSP graduates per gender and year.

100 90 80 70 60 50 40

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30 20 10 0 Figure 2. FMUSP graduates’ percentage per gender and year.

In 1944, in order to supplement the Medical School education system, Hospital das Clínicas was inaugurated. The School principal took office as president of the Board of Directors of the hospital. Its construction was one of the requirements made by the Rockefeller Foundation to the São Paulo State administration at the time the donation was made. Several institutes belonging to the Hospital were inaugurated thereafter, and today they comprise the greatest hospital complex in Latin America: Institute of Psychiatry (1952), Institute of Orthopedics (1953), Nuclear Medicine Center (1959), Tropical Medicine Institute (1960), Children’s Institute (1970), Heart Institute (1975), and Policlinic Building and Convention Center Rebouças (1979). The Radiology Institute and Ancillary Hospitals Suzano and Cotoxó are also part of the complex. In 2000, the astonishing number of 11.5 million appointments and 53 thousand hospital confinements were made (Lacaz, 2000; Medical School Foundation, 2001).

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In 1951, FMUSP teachers’ efforts to meet good education standards were rewarded by the recognition of the US Medical Association, which classified the School as one of the forty class “A” foreign schools. FMUSP was the first medical school in Latin America and the fifth in the world to fall under this classification, excluding US schools. It is worthwhile mentioning that in 1945, for the first time in Brazil, Hospital das Clínicas instituted the medical residency program, and in 1973 implemented a medical post-graduate course at FMUSP (Lima Gonçalves, 1992). In 1968 came the creation of the Experimental Course on Medicine, which proposed a new curriculum that emphasized generalist doctor education. A few years later, in 1976, Experimental and Traditional Courses were amalgamated and the number of FMUSP vacancies was raised to 180. From 1969, as a result of the University Reform, FMUSP was required to transfer, almost in its entirety, the basic cycle to the São Paulo University City Campus, which adversely affected education and research. In 1998, a new curriculum was implemented at FMUSP—the Nuclear Curriculum—which introduced new disciplines in the first year such as “Introduction to medicine”, “Humanistic bases in medicine” and “Human behavior”; the latter two were suggested by Prof. Paulo Vaz Arruda (Marcondes, 2001). The new Curriculum was a response to the uncontrollable overload of information that involved the medical course, the increasing de-humanization in medicine, and the amalgamation of basic and clinical courses. The nuclear curriculum is obligatory and responsible for 70% of total course load. The supplemental curriculum, which comprises optional disciplines and training, and is offered from the first through the sixth year, is responsible for 30% of total course load. Furthermore, in order to take students away from anonymity and restore the teacher-student relationship, the Tutoria Project was created and implemented in 2001. Such innovative measures resulted from fifteen years of hard work for the FMUSP Medical Education Development Center (CEDEM) members (Millan, 1999; Montes, 2000; Bellodi; Martins, 2001).

Profile of FMUSP Students For the purpose of knowing the profile of FMUSP students and alumni, CEDEM carried out three surveys. In the first (Lima Gonçalves and Marcondes, 1991), with the aid of the Regional Council of Medicine of the State of São Paulo, 3,309 letters were sent to alumni who had graduated from 1958 through 1989. Among them, 75.9% resided in the City of São Paulo, 6.7% resided in the Great São Paulo Area, and 17.4% resided in the countryside. From all questionnaires sent, 28.4% were answered, particularly by those residing in the countryside and graduated from experimental courses. Ninety percent of the alumni participated in the medical residency program, 29% attended post-graduate courses, and 82% used to read medical publications regularly. Before graduating, 3% attended other colleges, generally health-care-related courses, such as pharmacy, nursery and hospital administration, and to a lower degree other courses such as business administration, engineering, and theology. After graduating, 10% of the alumni attended other courses, particularly hospital administration, medicine at work and public

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health, which are actually specialization courses. Among the courses related to other fields, Business Administration, Philosophy and Law should be mentioned. About 37% alumni teach classes in medical courses, particularly at Hospital das Clínicas (11.1%) and FMUSP (8.9%). Approximately 75% alumni work as independent workers and 22.8% are salaried employees. According to them, working as independent workers is more advantageous as to financial aspects, professional independence, and relationship with colleagues and patients. Working as college teachers is more advantageous when reaching good technical-scientific standards and gaining prestige are concerned. When asked about financial gains provided by medicine in comparison with other college-graduated professionals, 52% alumni deem them satisfactory, 29% not very satisfactory, and 10% unsatisfactory. Alumni who work in the countryside are more satisfied in relation to such aspect. Other activities such as cattle-raising, agriculture, consortium, civil construction, and working at micro companies are carried out by 11% alumni, and 14% of them answered that they had thought about abandoning medicine. In 1992, CEDEM published a survey about the Profile of Students from the Medical School of the University of São Paulo carried out in 1991. Seven-hundred-six questionnaires were answered, thus representing 63.6% of total students enrolled in the medical course. Some prominent aspects are: • •

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•

•

•

The percentage of students who deem excessive the competition at FMUSP increases from 19% in the first year to 88% in the sixth year. Male students are more used to missing classes than female students because the first deem classes uninteresting. The attributes male students most admire in teachers are: knowledge, experience and competence (49%), good didactics (32%), interest, goodwill and devotion (24%), objectivity, synthesis, clear-headedness (16%), and finally, good relationship, accessibility and affinity (16%). Female students attach more importance to didactics and objectivity. The attributes male students most disapprove of in teachers are: lack of didactics (31%), arrogance, prepotency and pride (31%), ignorance, lack of skillfulness, and incompetence (21%), lack of interest, ill-will, and impatience (19%), and finally lack of timeliness (14%). Other deficiencies such as moralism, reactionaryism, smoking in the classroom, machismo and boring teachers were also mentioned. In regard to curricular structure, 54% of students complained of excessive course loads, short vacation times and lack of time-off. Dissatisfaction increases over the course. As to personal aspirations, 33% of students answered that they would like to be competent, good, and devoted doctors, and keep themselves up-to-date. They would also like to have a chance to study abroad. A second group consisting of 21% of the students pointed out their interest in personal success, which appeared in answers such as earning money, achieving fame, success, participation in the international medical community and becoming an official teacher. Furthermore, 12% of students pointed out their search for personal happiness in answers such as: to be free, happy, travel around the world and enjoy youth. Personal achievements (11%) were

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• •

expressed in answers such as: to reach maturity, safety, tranquility, and balance among personal, family and professional lives. A group consisting of 10% of students gave answers related to professional issues such as to have a private office, work in the countryside, carry out research and work at hospitals. Finally, 5% of the students mentioned personal predicates such as to be good, fair, honest and useful. Only five students reported vocational related doubts. More than 95% of students answered they would like to attend residency. As to socioeconomic profile, 53.8% of students belonged to class A, 40.5% to class B, 6.1% to class C and only 0.7% to classes D and E. In the same year, surveys showed that 50.5% of students from the University of São Paulo (USP) belonged to class A, 32.6% to class B, 13.6% to class C and 3.0% to classes D and E, which shows lower socioeconomic conditions in comparison with FMUSP students (Cabral et al., 1992).

In 2002, CEDEM also published the work FMUSP students’ profile in year 2000. In that year, about 75% of students answered a questionnaire; 62% were male students. Some results are summarized below: •

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• •

•

•

• •

In 2000, only 17% of freshmen admitted hard competition among students. However, in the second year this percentage is raised to 51% and reaches 65.5% in the fifth year, but decreases to 55% in the sixth year. There is, therefore, a slightly friendly relationship among students in relation to the former survey, where 88% of sixth-year students deemed the FMUSP environment excessively competitive (Bellodi; Cardillo, 2002). In 2000, 51.2% of students consider the course load suitable, 17.6% deem it excessive, and 5.5% deem it insufficient. In 2000, 54.2% of students answer they are used to going after teachers to get information and advice, and 84% of the students report that they are kindly received. About 40% of students are not used to looking for their teachers. Truancy takes part in the routine of 29.8% of students, because they consider classes uninteresting (43.6%), or have other activities (20.4%), or lack motivation (15.1%), or else deem classes unnecessary (13.7%) (Mascaretti; Santos; Cardillo, 2002). In decreasing order of importance, students consider that teachers’ main attributes are: knowledge, interest, didactics and experience. The major deficiencies pointed out are: first of all, lack of didactics, followed by lack of interest and arrogance (Lima Gonçalves, 2002). In 1991, the number of students who hadn’t read a non-medical book in the last six months was greater than in 2000 (36% in 1991 x 31% in 2000). In 2000, 25.7% of students answer that they have chosen the medical profession because of their desire to help other beings, followed by interest in biology (19.5%), social concern (18.0%), economic interest (11.6%), family influence (8.4%), social status (6.6%) and by exclusion (6.3%). Considering only the 148 freshmen answers, 80.4% checked the alternative “desire to help other beings”; 59.5% checked “social concern”; 48.6% “interest in biology”; 27% “economic interest”; 20.3% “family’s

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influence”; 14.9% “social status”; 10.1% “by exclusion”; and 13.5% “other reasons”. It is worthwhile mentioning that answers were stimulated by predetermined alternatives. If they could go back in time, 86.6% of students would choose to attend the medical course at FMUSP (93.9% freshmen); 3.1% would take the course in another school (0.7% freshmen), and 6.8% would choose other careers (2% freshmen) (Mascaretti et al. 2002).

Psychological Aspects of FMUSP Students “Every teenager carries a veiled world, an admiral, and an October sun inside.” Machado de Assis

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Entering Medical School After passing the most difficult selection exam to enter FMUSP—the so-called “vestibular exam” issued by the Brazilian foundation FUVEST—students feel socially recognized and proud of their performance. On an omnipotent basis, they believe that all problems have come to an end and from now on becoming a doctor is just a matter of time. For some of them, the simple fact of studying medicine already licenses them as doctors, an illusion reinforced by their families who ask their advice when someone is ill. Paradoxically, when a medical student graduates, many people say: be careful! He/she’s newly graduated! Reception and sports competitions also contribute to the party fun-atmosphere and reinforce the appearance of manic defenses (negation, omnipotent control and dissociation) that prevent students from getting in touch with very intense anguish that emerges in view of so many novelties and changes: teachers, classmates and education method. This transitory phase is called the euphoria phase. This is followed by a disenchantment phase, when several complaints against didactics, long classes, excessive volume of study, and little usefulness of the courses, which are now seen as theoretical and apart from medicine itself, arise. Because a majority of classes are given at the University City instead of the FMUSP building, students feel bothered by this impersonal environment in an important moment for establishing their medical identity. Disenchantment increases with the result of the first tests, which is below the expectations of students who were accustomed to being the first in the class and recognized as such by others and themselves. The loss of such status may affect the student’s self-image and trigger an identity crisis, feelings of unworthiness and a desire to abandon the course. To make things worse, by the end of the year a feeling of having learned absolutely nothing or having forgotten the disciplines taught over the year emerges. Furthermore, it is difficult to integrate different disciplines and find out how useful each of them might be. Countryside students, in addition to facing such difficulties also have to adjust to the big city and take responsibilities

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that were handled by their families before. Finally, there is also the mourning over losing time to spend at leisure and with friends, family and sweethearts. In the third and fourth years, affinity groups are formed. Their members will be together over the next stages of the course. At this time, the fear of staying with the “mob”, that is, to be rejected by classmates and stigmatized by teachers, arises. During this stage, a resentment for depending financially upon their families and the strong competition for the best grades and prominence in the so-called “hidden curriculum” (participation in leagues, prepositor’s works, courses, congresses, on-duty works and scientific works) can be noted among students. Because of the Nuclear Curriculum and optional disciplines, the hidden curriculum may lose importance. During the internship (fifth and sixth years) students face new challenges. After a long time of eminently theoretical study, they now start to effectively take care of patients and check what they have learned. From doctor-patient relationships they apprehend the limitations of their performance and hospital conditions, and often feel impotent and disappointed in relation thereto. The professional reality is far away from their healing, salvation and control over life and death fantasies that have so far been part of their lives. Their observation is then focused on everything they don’t know or cannot do, which reinforces their feelings of inadequacy, inoperability and guilt (Millan et al., 1991). When on-duty works are implemented, students feel difficulties in planning their time, and feel resentful for their exclusive and exhaustive dedication to medicine. Because they are going through a transition time between an academic model and becoming a professional, they need to elaborate new losses and, concomitantly, put egoic resources into motion. The relief they expect to feel when the course is close to an end is not accomplished, because it is time to choose a specialty and face a residency selection process. According to Pessanha (2001), the graduation ceremony at the end of the course accelerates the students’ entrance to the adult world, with its doubts, uncertainties, and responsibilities. In view of the foregoing, students usually have the feeling of being flooded with insurmountable difficulties. However, when this feeling is overcome, internship may be seen as a stage that offers them good opportunities to become mature and make new discoveries (Millan et al., 1991).

Psychopathological Disorders In general, humor disorders prevail among FMUSP students, being followed by anxiety and personality disorders, with special emphasis on the obsessive personality. Psychotic disorders are unusual, and the use of drugs, although worrying, is half that of other students from the University of São Paulo, except for alcoholic beverages. In practice, drug addiction, although rare, has serious consequences for students and their relations with patients and their professional future. It is worthwhile mentioning that these findings are consistent with what happens in medical schools established in other countries with clear cultural differences. Until the middle of the 80s, the number of suicides among FMUSP students was high (39/100,000 students/year), exceeding four or five times the ratio of the São Paulo municipality population in the same age band. Ever since, fortunately, the number of suicides has drastically decreased. From 1986 through 2000, there was only one suicide event while a

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number six times greater would be expected if the former pattern was maintained. It should be pointed out that some US works also reported a great number of suicides among medicine students (Simon, 1968; Grover and Tessier, 1978; De Armond, 1980; Pepitone-ArreolaRockwell et al., 1981; Bjorksten et al., 1983; Millan et al., 1990; Baldwin, 1991; Chan, 1991; Wolf, 1994; Andrade et al., 1995; Millan et al., 1999; Millan, 2001).

FMUSP Students and Medical Vocation

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From the conscious viewpoint, the most common reasons mentioned by FMUSP students for choosing a medical career were: interest in biology, third parties’ influence (particularly doctor parents), chance to help and treat others, engagement in social activities, and desire to stay close to people. Nowadays, a few students choose the career because they want status, good financial compensation or to work as independent workers, which shows that they are aware of the changes occurring over the last years in relation to such aspects (Millan et al., 1991). The most common unconscious motivations assessed were described in the former chapter. Rossi et al. (1999) interviewed teachers and students from the School of Medicine of the University of São Paulo. They were asked if they believed in the medical vocation and what was the reason for choosing it. It is possible that many motivations given have been unconscious for a certain time, but by the time they were reported, they obviously became conscious. Part of such statements is transcribed below: Adib Domingos Jatene I think that circumstances can make you go this or that way. And vocation is a thing that I question sometimes… And I always say: you’d better like what you do than do what you like … My father was a merchant. He died in 1931, when I was only two years old… My mother always complained that he had had no assistance and that’s why he died. Maybe this idea has remained in my unconsciousness (Jatene, 1999, p. 156). Carlos da Silva Lacaz I believe in medical vocation. I chose the medical career because I was influenced by two family doctors from the São Paulo State countryside. I wanted to serve human beings (Lacaz, 1999, p. 165). Eduardo Marcondes I believe in medical vocation. In my lectures and conferences I used to say that maybe there is a gene… Since I was a little boy I never had any doubt about my profession. Certainly because of the environment that surrounded me… My father was a successful doctor; and my uncle, even more. And I admired them for that beyond words! Maybe it is where my choice for the medical career originates from (Marcondes, 1999, p. 175). Milton de Arruda Martins This is a difficult question to answer but I tend to believe that yes, there is medical vocation. I think that if we take a look at the students who enter a medical school we see a very heterogeneous group. However, within such heterogeneous group there is a group that carries this thing more clearly within: it has to do with helping others, relieving pain. And I do believe that. But I don’t think this is the only factor, and it certainly may be more important

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Luiz Roberto Millan in some people than in others. I see medical school freshmen who had chosen the medical career to become plastic surgeons because this is a money-making specialty… When I was a student I liked everything. In fact, I chose medicine because I had this idealization that medicine would be a career that would allow me to work with people. And I preferred people to numbers (Martins, 1999, p. 185). Paulo Corrêa Vaz de Arruda Yes, I do believe so! I believe in medical vocation, maybe not in actual terms from a scientific viewpoint, but in terms of generosity and ability to dedicate to others. I chose medicine maybe in agreement with Blaya, who says: “because I had so many painful vicissitudes in childhood I have decided to take care of myself through others”. Maybe this is an explanation! I like to talk about that in vocation classes I give. Maybe the so many physical disorders I’ve been through have awakened this in me. But what I really wanted to do was to understand the character, I mean, probably myself! I have always been interested in understanding others (Arruda, 1999, p. 192). Tales de Brito I do not believe in total vocation, except for special cases. But I believe in a greater adjustment, according to the circumstances… I like both medicine and architecture. I like drawing. But in medicine I chose an imaging related specialty, which sticks close to everything I like (Brito, 1999, p. 201).

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FMUSP Freshman I’m not sure whether there is vocation or not, a gift a person might have. I think that after reaching maturity anyone may find a profession. It is not a matter of being “born with the gift to be a doctor, a lawyer or an engineer”. I decided to study medicine because I have affinity with the medical career… Once I traveled to the State of Rio Grande do Sul and had to assist a laboring woman. It was on that occasion that I found out how much the medical field was drawing my attention. If I had to go to a hospital I was fascinated. I had a connection with biological sciences… (p. 214). FMUSP Second Year Student I do believe in vocation! I think that there are people who want to help and are qualified to deal with others… I chose to study medicine because I like to help people and make them feel better. I think that both physical and psychological health is important to make people feel well (p. 217). FMUSP Third Year Student I believe so. But I also think that great part of what is supposed to be vocation is fantasy, that is, an idea created in childhood under family influence or related to family’s expectation. I chose medicine for a simple reason: the necessity of knowing human beings as a whole, integrating physical part into psychological part (p. 220). FMUSP Fourth Year Student Well, following the medical career, either general clinic or surgery, requires a little bit of vocation, unless you engage in research, which does not require that vocation or desire to practice medicine… I think that enjoying what you do is somewhat vocation. I don’t know it for sure because vocation is quite subjective. I cannot define exactly what vocation is… I started to study medicine because I had always thought of it. I had no doubts about it by the time I chose my career… (p. 225).

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FMUSP Fifth Year Student I believe that human beings have a certain vocation to do a certain thing. I don’t know whether we are born with a gift or not. I think that we might be able to create this gift. I chose medicine at first for very personal reasons. I could not accept death. I wanted to fight against it. This concept has changed over the medical course, until I realized that there are limitations on saving lives. This is very relative: saving. I believe that a certain human tendency to kindness is necessary when you choose such a career and share others’ pain. The great difficulty is to share the pain of others without excessively suffering with them (p. 231). FMUSP Sixth Year Student I do believe in medical vocation. However, this is a paradox to me because I did not choose medicine for vocation. I had a taste for science and not for the practice of medicine itself, whether as clinical doctor or surgeon. I considered some practical aspects at first: a profession that could provide certain stability. And I enjoyed studying it. I was pleased to be in contact with it. But my great interest was in science. When I entered college I wanted to be a scientist and work at the lab. Now things have changed… (p. 235).

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Finally, it should be noted that most statements emphasize the existence of medical vocation and the important role altruism plays in this field. Some students and teachers, however, questioned the existence of vocation, what evidences that this issue is very polemical. This issue will be deeply analyzed in Chapter 6, where the outcomes of the survey carried out with FMUSP freshmen are discussed.

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Chapter 6

6. A Survey of Students from the School of Medicine at São Paulo University (FMUSP) Introduction

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In order to contribute to the study of the medical vocation and its relation to gender, we carried out a survey of a freshmen group from the School of Medicine at the University of São Paulo (FMUSP) during the year 2000. Participating in this project, together with the author of this book, were Prof. Raymundo Soares de Azevedo Neto, Prof. Paulo Corrêa Vaz de Arruda, and psychologists Eneiza Rossi, Orlando Lúcio Neves De Marco and Marília Pereira Bueno Millan. The purpose of the survey was to ascertain whether there are differences as to gender in the following aspects: • • • • • • • • • • • •

socioeconomic profile time when career choice is made gathering information about a medical career before college admission tests (vestibular) significant identification with others while choosing the career discouragement of choosing a medical career image of the profession expectations as to undergraduate courses career expectations attributes considered important for being good doctors successful doctor’s image personality traits unconscious psychodynamic aspects tied to a medical vocation.

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Methodology The population under analysis consisted of 163 freshmen of both genders between 17 and 21 years of age from the School of Medicine at the University of São Paulo (FMUSP) in the year 2000. These 163 medical students (90% of the 175 freshmen, being 35% female students) were present at the reception meeting and answered a questionnaire regarding their socioeconomic profile. Of those, keeping the age band proportionality as to the general sampling, thirty female students were selected at random. Thirty male students were then selected to pair the socioeconomic variables. Subsequently, the sixty students were submitted to a face-to-face interview with the author of this book and then submitted to the Thematic Apperception Test (TAT) and the 16 PF Test, which were conducted by psychologists Marília Pereira Bueno Millan, Eneiza Rossi and Orlando Lúcio Neves De Marco.

Survey Tools Questionnaire for Assessing Socioeconomic Profile

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For this survey, a questionnaire for ascertaining the students’ socioeconomic profile — containing questions about gender, age, race, birth place, religion, marital status, parents’ academic degrees and occupations, existence of doctors in their families, number of times they had tried to enter the medical school (the aforesaid hard selection exam called “vestibular” in Brazil), information about fundamental and high-school courses, premedical courses, and other college courses they had attended, family income structure, remunerated activities, how living/maintenance costs would be born during the medical course, dwelling place, and family income — was prepared.

Semi-Directed Interview about Career Choice A semi-directed interview was prepared in order to evaluate the following aspects: time when career choice was finally made; the conscious motivation for choosing medicine as a career; interest in searching information about the medical profession; whether alternative career choices were considered; identification with an acquainted doctor; advice against a medical career; early medical specialty choice; opinions about the medical profession nowadays; expected undergraduate difficulties; expectations toward their future; the career’s influence on their private life; choosing to get married to a doctor; the five most important attributes a good doctor must have; what attributes cannot be taught to a doctor; selfevaluation in relation to those attributes; and how to become a successful doctor. The interviewer used the phenomenological approach.

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The Thematic Apperception Test (TAT) The Thematic Apperception Test (TAT) was developed by Murray et al. at Harvard University and published for the first time in 1935 in the magazine Archives of Neurology and Psychiatry. The sixty-year-old test is laudable for its fecundity. Four heirs were created therefrom: CAT (Bellak), Picture Test (Symonds), Rorschach, and Object Relations Test (Philipson). Greatly disseminated, TAT has not become old. On the contrary, it grew stronger with the practice, the surveys and an important bibliography. In 1958, Shentoub’s work brought a valuable contribution to TAT validation (Jacquemin et al., 1993; Weneck, 1995). Souza (1995) demonstrated its effectiveness as a diagnosis technique. According to Murray (1995), TAT is a method designed to unveil significant impulses, emotions, feelings, complexes and conflicts. Its most important value lies in its capacity to show unconscious trends, which the subject does not want or is not prepared to accept. Therefore, this is a useful tool for any comprehensive study about personality. Several pictures are shown to the subject, who is asked to tell a story based upon them. The stories should be created in an impulse, at the very moment. The stories then gathered often unveil significant personality traits, since two important psychological tendencies are displayed: the first is the tendency people have to interpret an ambiguous human situation based upon their past experiences and present desires; the second is a tendency human beings have to express their (conscious and unconscious) feelings and necessities while telling a story. This is, therefore, a projective test. According to Murray (1995), more often than not TAT reveals exactly the opposite of what the subject seems to be and what he/she voluntarily does and says in his/her daily life. Souza (1995) points out that to a certain extent the projective situation is empty, and the subject usually fills-in such emptiness by resorting less to intelligence than to inner resources. Moraes Silva (1989) says that the expression “projective methods” was created to designate a set of instruments that seek to approach the subject as to their particularities. In opposition to the psychometric tradition, under which a classification using basically quantitative and normative procedures is made, here qualitative and psychological aspects are emphasized. According to him, TAT is today one of the most important tools used by clinical psychologists for investigating the subject’s personality. The test allows the identification of the subject while facing several situations, and his/her fears, desires and difficulties, and most of all his/her personality dynamics. The idea that artistic productions reveal the artist’s personality was born before Freud’s time. Leonardo da Vinci said that “the artist tends to place his own bodily experience on the pictures he creates” (p. 3). In 1855, Burckhardt analyzed Renaissance works and tried to identify the personality of their authors. Freud also considered such possibility, and in 1907 he published his analysis of Jansen’s Gradiva novel. In the same year, Buttain created a test for investigating imagination. He used figurative materials to stimulate the creation of stories, and that is why he is considered to be TAT’s precursor. Cunha et al. (1993) mention that Murray, the TAT’s creator, based on psychoanalytical assumptions, defines personality as a dynamic organization of competitive forces within an individual. The main indication of the test lies in the assessment of psychodynamic aspects of the personality, that is, the understanding of the subject’s affective ties, which is of utmost

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importance to a doctor-patient relationship. The use of projective tests reached its apogee in the middle of the 20th century. Nevertheless, a research study carried out on twenty-two US clinical services indicate TAT as the fifth most used technique among psychological tests in general. In our field, after its indicators being defined and validated, it has become an important psycho-diagnosis instrument, which is also used in surveys. Recent specialized literature shows that TAT is used in studies of personality, gender, family and object relations, sociability, among others (Shill, 1981; Nasby; Read, 1997; Ackerman et al., 2001; Kwon et al., 2001; Schultheis, 2001). Also noteworthy is the fact of Bohoslavsky (1977), in his classical book about vocational advisory, suggesting the use of TAT in the face of a doubtful diagnosis in the vocational field. He asserts that, despite the lack of specific vocational guidance tests, some tests such as TAT provide psychologists with important data about the personality of the subject. According to Freitas and Costa-Fernandes (1993), because it is essentially indicated for a dynamic understanding of personality, and on the contrary to other tests, TAT offers, on a subsidiary basis, information for a nosological classification. Emphasis is made on strictly qualitative aspects; and the efforts employed for developing score systems for TAT have produced no favorable results. TAT material consists of nineteen printed pictures which, together with a blank card, give rise to twenty stories. For the purpose of reducing the test and applying it in only one session, psychologists usually use abbreviated forms and select those pictures that science has shown to be the most stimulating for producing the material. Some pictures evoke issues and evaluate personality aspects that are weighty to professional career choice (Murray, 1995). In this survey, we have selected five TAT pictures whose themes are deemed outstanding to the medical vocation study. Picture number one shows a boy contemplating a violin. Picture number two shows a field landscape: in the foreground a young lady holds some books in her arms and on the background a man is working while an old lady observes him. Picture 3RH shows a young man on the floor leaning over a divan with a gun by his side. In 8RH a teenager looks straight out of the picture. A rifle barrel is visible on one side and in the background a dream-like diffuse surgery scene is visible. Picture number twenty shows a human figure leaning against a light post with a dim light on a dark night (Murray, 1995).

Sixteen Personality Factor Questionnaire—16 PF Fifth Edition In order to evaluate normal personality in teenagers and adults, Cattell et al. developed, in 1956, the 16PF or Sixteen Personality Factor Questionnaire. Several personality scales had already been elaborated on the basis of the supporting psychological theory so as to define the main personality traits of the subject. The 16PF, in turn, was built otherwise: firstly, based on surveys and factorial analyses, the basic personality traits and structures were assessed; and subsequently, a test for evaluating sixteen traits that embody the whole personality area was prepared. The factorial analysis used for elaborating the 16PF is a statistical technique used to detect variables that jointly constitute broad dominance. Cattell et al. selected 4,504 personality traits from English dictionaries and psychiatric literature. With the aid of a

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previous list made by Allport and Odbert, this number was reduced to 171. The use of the factorial analysis led to fifteen traits (primary factors), to which intelligence was added. Based on the primary factors, the factorial analysis was also used to find five global personality factors. The test has scales for evaluating Response Style: Impression Management Scale (IM); Infrequency Scale (INF); Acquiescence Scale (ACQ) (Cunha et al., 1993; Russel; Karol, 1999). The 16PF fifth edition standardization for the Brazilian population was made in 1998 with 1,152 students, five hundred of them from college. Among its several applications, the test is used to ascertain occupational profiles among different occupations. Its reliability (reproductiveness) and effectiveness (measuring aspects that it actually proposes to measure) have been proven in several studies made in several countries (Cattell; Eber, 1997; Russel; Karol, 1999). The 16PF approaches 185 items that constitute the sixteen Personality Primary Factors and an Impression Management index. Each scale embodies ten to fifteen items, which should be answered in full within approximately 50 minutes. When raw scores are compared to the standard sample they are transformed into stens, which are based on a ten-point scale, with a mean of 5.5 and standard deviation of 2. Historically, sten scores ranging between 4 and 7 are interpreted as a mean; between 1 and 3 as low; and between 8 and 10 as high. In theory, 68% of the population gets scores within the median band, 16% upper, and 16% lower. Most scales have a standard error of measurement (SEm) close to one sten score point, which allows a 68% confidence interval. For a 95% confidence interval, the range is 2 scores above or below the mean, that is, for a sten score equal to 8 there is a 95% chance of the examinee getting a sten score between 6 and 10. Because scales are reduced and are only an estimate of the examinee’s personality factors, the interpretation of scores falling next to mean score limits should be made with caution. The test is self-manageable and all questions have three alternative answers, the answer in the middle being a question mark. The examinee is advised to answer all questions with the first answer that comes to his or her mind. The alternative (?) must be checked when the other two answers are inadequate. A summarized description of global and primary factors and the Response Style is made below (Cattell; Eber, 1997; Russel; Karol, 1999). Primary Factors Factor A – Warmth (Reserved vs. Warm); Factor B – Reasoning (Less Intelligent vs. More Intelligent); Factor B - was excluded because the group of students under analysis entered the medical course after passing a broad cognitive selection exam (the college admission test – “vestibular”); Factor C – Emotional Stability (Reactive vs. Emotionally Stable); Factor E – Dominance (Deferential vs. Dominant); Factor F – Liveliness (Serious vs. Lively); Factor G – Rule-Consciousness (Expedient vs. Rule-Conscious); Factor H – Social Boldness (Shy vs. Socially Bold); Factor I – Sensitivity (Utilitarian vs. Sensitive);

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Luiz Roberto Millan Factor L – Vigilance (Trusting vs. Vigilant); Factor M – Abstractedness (Grounded vs. Abstracted); Factor N – Privateness (Forthright vs. Private); Factor O – Apprehension (Self-Assured vs. Apprehensive); Factor Q1 – Openness to Change (Traditional vs. Open to Change); Factor Q2 – Self-Reliance (Group-Oriented vs. Self-Reliant); Factor Q3 – Perfectionism (Tolerates Disorder vs. Perfectionist); Factor Q4 – Tension (Relaxed vs. Tense).

Global Factors The five global factors are constructed through equations that use the limits of a Primary Factor Scales set. High Warmth (A+), Liveliness (F+) and Social Boldness (H+) scores, for instance, increase Sensitivity (Factor I). The same applies to low Privateness (N-) and SelfReliance (Q2-) scores. Most examinees (78.6%) have median scores on the global factors or extreme scores on one or two factors, while only 6% have extreme scores on four or five factors. If examinee is, for instance, extroverted on all primary scales related to extraversion, this means that he or she probably gets close to people on a consistent basis. If examinee is extroverted on some primary scales and introverted on others, he or she will probably be in conflict with the places on which he or she expresses extraversion. The greater the extreme scores the more remarkable the personality expression will be.

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Factor I – Extraversion (Extroverted vs. Introverted) Factor II – Anxiety (Anxious vs. Impassible) Factor III – Tough-Mindedness (Tough-Minded vs. Receptive) Factor IV – Independence (Independent vs. Subdued) Factor V – Self-Control (High Self-Control vs. Low Self-Control). Response Style Impression Management (IM) Scale The Impression Management (IM) Scale measures social desirability and consists of twelve items of the questionnaire. High scores may reflect response distortion on the part of the examinee, who might be seeking to please the examiner and making a good impression, or may indicate that the examinee is actually capable of exhibiting socially desirable behavior. Percentiles above 95 or below 5 are considered extreme and in case open distortion is suspected, re-testing should be considered. Infrequency (INF) Scale The Infrequency Scale (INF) comprises thirty-two items of the questionnaire in which the number of alternative “b” answers [?], which means “doubt” or “I cannot decide”, is ascertained. Percentiles equal to or higher than 95 are deemed high. Possible explanations for high INF scores are: casual answers, inability to decide, difficulty to read or attempt to disguise what the examinee considers seeing in himself.

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Acquiescence (ACQ) Scale The Acquiescence Scale (ACQ) measures the tendency to answer as “true” an item without considering its content. The scale consists of 103 items on the questionnaire, and percentiles equal to or higher than 95 are deemed high. High ACQ scores may indicate that the content of some questions has not been quite understood, answers were given at random, choosing a self-descriptive answer was difficult, or there was a need for approval.

Analysis of the Results Socioeconomic Profile Questionnaire After summing-up the answers checked by male and female students, a quantitative analysis of the socioeconomic questionnaire answers was made.

Semi-Directed Interview about Career Choice The answers given to open questions during the semi-directed interview were categorized in order to allow a comparison between male students and female students.

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Thematic Apperception Test (TAT) TAT pictures were interpreted by Marília Pereira Bueno Millan, a psychologist with great experience in the psychoanalysis field and deep knowledge about the test. As proposed by the author of the test (Murray, 1995), the analysis was totally qualitative and sought to compare psychodynamic aspects of male students with those of female students.

Sixteen Personality Factor Questionnaire (16PF Fifth Edition) The 16PF scores were computed electronically by a computer program provided by the editors.

Statistical Analysis Socioeconomic Profile Questionnaire In order to ascertain differences in respect to gender, each aspect of the questionnaire was summed-up and categorized, if necessary, into groups of answers and analyzed by 2 Test or Fisher Exact Test. The level of significance was fixed at 5% (α = 0.05).

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Semi-directed interview about the career choice After categorizing the interviews, answers were analyzed by 2 Test or Fisher Exact Test, as appropriate (tables having cells with expected values lower than five). The level of significance was fixed at 5% (α = 0.05).

Sixteen Personality Factor Questionnaire (16PF Fifth Edition) General profile of factors — comparison between genders: The general profile of factors assessed in male and female students was compared according to the coefficient of profile similarity rp, as proposed by Cattell and Eber (1997). The coefficient rp ranges from -1.0 to +1.0, and rp higher than 0.5 indicates similarity between both groups. Raw scores and stens on each factor — comparison between genders: In order to compare raw scores and sten scores on each primary factor, stens on global factors and percentiles of Response Style in male and female students, the non-parametric test Mann-Whitney with significance level at 5% (α = 0.05) was used.

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High and low limit stens — comparison between genders: The number of male and female students falling outside 4–7 sten scores, which are deemed normal for the Brazilian population, was ascertained. Then the 2 Test, with level of significance set at 5% (α = 0.05), and Fisher Exact Test, as the case might be, were applied (tables having cells with expected values lower than five). Statistical tests were carried out through software SPSS version 10.1 for Windows.

Project Evaluation and Ethical Aspects The project of this research was submitted to the Ethics Committee for Research Project Analysis at Hospital das Clínicas and FMUSP and approved without changes (filing certificate no. 746.98). At each stage of the research, students signed a document in order to evidence their agreement to participate in the project.

Results Socioeconomic Profile Questionnaire The 60 students enrolled in the study have the same age band, with a great prevalence of students between 18 and 19 years old (p = 1).

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As to race, no statistically significant difference between both groups (p=0.411) was found. Most are Caucasian (76.66%), followed by Asians (21.66%) and only one Black student (1.66%). All of them are Brazilian citizens and single. Most of them were born in São Paulo City, the Capital of the State of São Paulo (46), followed by those born in the São Paulo State countryside (11) and coast (3). Two of them were born in the State of Minas Gerais. A significant number of students (30%) follow no religion, and no significant difference between genders was ascertained in this regard (p=0.573). Among religion followers (70%), most are Catholic (34), followed by Spiritists (5), and others (3). No statistically significant differences between both groups were found (p=0.832). Most students’ fathers (80%, p=0.33) and mothers (81.66%, p=0.506) have college degree, and 25% fathers (p=0.765) and 8.33% mothers (p=0.353) are physicians. No statistically significant differences between both groups were found. The presence of doctors among family members of the students is remarkable (63.33%), with identical distribution between genders (p=1). Most of them attended elementary (83.33%) and high (93.33%) school in private (nongovernment) institutions. In fact, only one freshman (1.66%) had studied exclusively at public schools. Most students had attended a preparatory course for vestibular (p=0.600) and only 26.66% succeeded in their first attempt to enter college, while 41.66% tried twice and 31.66% tried three or more times (p=0.702). Only three students attended other college courses before the admission test for medical school (p=0.554). In all such items no statistically significant differences between genders were ascertained. The monthly family income of 66.66% students was above twenty minimum salaries (the minimum salary corresponds to US$210.00), 30% was between ten and twenty minimum salaries, and 1.66% was between five and ten minimum salaries (p=0.508). Fathers are the major providers for 75% families (p=0.600), and 96.66% students are not engaged in remunerated activities (p=0.355), 81.66% do not intend to have a job during the medical course (p=0.475), and 76.66% expect to live with their families during the medical course (p=0.361). In all such items no statistically significant differences between genders were ascertained. Finally, it should be pointed out that no statistically significant differences between genders were ascertained as to all aspects analyzed in the socioeconomic profile questionnaire.

Interview The students selected for the second stage of the survey were notified by letter to attend a routine interview with the Psychological Counseling Group of the School of Medicine of the University of São Paulo (GRAPAL). Students were then asked whether they would be available to participate in one interview and two psychological tests. Unlike the first stage of the survey, when all students answered the socioeconomic profile questionnaire, here eleven (seven male and four female) students refused to participate in the study. The most usual reasons given for such refusal were lack of

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time, fear of missing classes, and desire to practice sports at the Athletic Center. Some of them were clearly fearful of exposing themselves during the psychological tests. Students were very cooperative during the interview and, in general, promptly answered the questions, except for the question about the necessary attributes for one being a good doctor, when greater latency periods were observed. In a few instances the interviewer’s intervention was needed to resolve a doubt, and in general students were at ease. In regard to the moment of choice, a great number of students (40%) stated that they had definitively chosen to follow a medical career before entering high school — below 15 years of age — which indicates a decision predominantly connected to affective aspects. Most of them, however, made their choice during high school (51.66%), a time when rational aspects are already present. A few students chose medicine thereafter (8.33%). No statistically significant differences between genders were ascertained in this regard. Altruism stands out as the main conscious motivation for choosing medicine, with forty answers, followed by curiosity and intellectual interest (23), interest in human relations (15), third parties’ influence (9), the profession’s profile (7), kind of work and workplace (2), and at last, financial compensation, with only one answer. No statistically significant differences between genders were ascertained (see Tables 1 and 2). Table 1. Conscious motivations for choosing medicine — according to gender

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Conscious Motivations ALTRUISM CURIOSITY AND INTELLECTUAL INTEREST INTEREST IN HUMAN RELATIONS THIRD PARTIES’ INFLUENCE PROFILE OF THE PROFESSION KIND OF WORK AND WORKPLACE FINANCIAL COMPENSATION

Number of Male Students 19

Number of Female Students 21

11 5 9 4 1 1

Total

P

40

0.78

12

23

1.00

10 4 3 1 0

15 13 7 2 1

0.23 0.21 1.00 1.00 1.00

Table 2. Answers categorized as altruism as a conscious motivation for choosing medicine, according to gender Answers HELP PEOPLE HELP THE NEEDY SAVE PEOPLE FROM DEATH RELIEVE PEOPLE’S PAIN FEEL USEFUL FOR HELPING OTHERS PROVIDE WELL-BEING TO OTHERS

Male Gender 19 3 1 1 1 -

Female Gender 19 1 1

Total 38 3 2 1 1 1

Most students (93.33%) sought information about a medical career before the college admission exam. The distribution of answers between both genders was the same, and Millan, Luiz Roberto. Medical Career Choice: A Gender Study : A Gender Study, Nova Science Publishers, Incorporated, 2009. ProQuest Ebook

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sources of information used were: acquainted doctors (47); visiting medical schools (15); lectures (14); communication media (9); books and manuals (4); joining doctors in medical appointments and surgeries (3); vocational counseling (3); medical students (1); Internet (1). About one-third of the students have considered enrolling in non-medical courses. From a statistical viewpoint, a significantly greater number of male freshmen identified themselves with someone else while choosing the medical career (p = 0.02), like doctor relatives (19), family doctors (7), doctor friends (5) and the movie character Patch Adams (1). Table 3. Specialties that freshmen considered choosing MALE GENDER PEDIATRICS (A) 5 PSYCHIATRY (A) 5 SURGERY (B) 6 NEUROSURGERY (B) 2 CARDIOLOGY (A) 3 GYNECOLOGY - OBSTETRICS (C) 1 PLASTIC SURGERY (B) 3 ONCOLOGY (C) 2 ORTHOPEDICS (C) 3 GENERAL CLINICS (A) 1 OPHTHALMOLOGY (C) 1 DERMATOLOGY (C) 1 IMAGENOLOGY (D) 2 RESEARCH (D) 2 NEUROLOGY (A) 1 HEART SURGERY (B) 1 INTENSIVE CARE (C) 1 ONCOLOGIC SURGERY (B) 2 CLINICAL IMMUNOLOGY (A) 1 SPORTS MEDICINE (A) 1 GASTROENTEROLOGY (C) 1 DIGESTIVE SURGERY (A) 1 NEONATOLOGY (A) TRAUMA SURGERY (B) GERIATRICS (A) INFECTOLOGY (A) PEDIATRIC ORTHOPEDICS (C) EAR, NOSE AND THROAT DISORDERS (C) LEGAL MEDICINE (D) TRANSPLANT SURGERY -

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SPECIALTY*

FEMALE GENDER 9 3 2 3 2 3 2 1 3 2 2 1 1 1 1 2 1 1 1 1 1 1

TOTAL 14 8 8 5 5 4 5 3 4 3 3 2 2 2 2 1 2 1 1 2 1 1 2 1 1 1 1 1 1

*A= cognitive fields; B= technical-surgical fields; C= intermediate fields; D= technological and bureaucratic fields.

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Luiz Roberto Millan

On the other hand, it is not unusual for future medical students to be told not to follow medicine as a career (both male and female students). Most of them had been discouraged by their mothers and friends (5), others by relatives (4), brothers/sisters and fathers (3), the family’s doctor (2), sweethearts and doctor friends (1). The great majority (76.66%) of students, with no significant difference between genders, said that by the time they entered college they had already thought about a specialty (Table 3). Cognitive fields rank first with 39 answers, followed by technical-surgical (25), intermediate (20) and technological and bureaucratic (5) ones. Table 4 – Answers related to the image of the medical profession nowadays, according to gender

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OPINIONS ABOUT THE CAREER LOW COMPENSATION TIME-CONSUMING LACK OF RECOGNITION WEAK LABOR MARKET POOR EDUCATION UNFAVORABLE WORKING CONDITIONS STRONG LABOR MARKET DIFFICULT DOCTOR-PATIENT RELATIONSHIPS PRECARIOUS SOCIAL ENVIRONMENT UNPLEASANT WORKING ENVIRONMENT (COMPETITION AND POLICIES) STRESSING REWARDING CAREER SOME DOCTORS ARE TRADERS MEDICINE HAS GROWN INHUMAN SOME DOCTORS ARE UNETHICAL EXCESSIVE NUMBER OF SPECIALISTS TOO MUCH RESPONSIBILITY ADVANCED TECHNOLOGY DOCTORS ARE UNITED BAD PSYCHOLOGICAL PREPARATION DOCTORS ARE ADMIRED A PROFESSION THAT HELPS PEOPLE SOCIALLY IMPORTANT PROFESSION DOCTORS ARE PEDANTIC

MALE GENDER 13 3 7 5 3 3 6

FEMALE GENDER 22 11 5 6 7 6 1

3

3

6

3

2

5

2

2

4

2 2 1 3 1 1 2 1 1 1 1 1 1

2 2 2 1 1 1 1 -

4 4 3 3 2 2 3 1 1 1 1 1 1 1

TOTAL 35 14 12 11 10 9 7

Only 10% of the students have a favorable image of the career nowadays, while 35% believe that favorable aspects go together with unfavorable ones. For most students (55%) there are only unfavorable aspects about the medical career nowadays. Female students tend

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to have a more unfavorable image of the profession, but no statistical difference was found between genders when the number of students was compared. Table 5 shows that students have optimistic expectations toward their professional future (both genders). Table 5. Answers related to students’ expectations toward their professional future, according to gender

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EXPECTATIONS SELF-FULFILLMENT GET A JOB FAIR COMPENSATION WORK AT A HOSPITAL BECOME A GOOD PROFESSIONAL WORK AT A PRIVATE OFFICE GRATITUDE FROM PATIENTS SELF-IMPROVEMENT ENGAGE IN SOCIAL ACTIVITIES TO BE RESPECTED BY DOCTORS WORK IN THE COUNTRYSIDE TO BE EVEN WITH THE FAMILY FEMALE DOCTORS FACE DISCRIMINATION DO NOT THINK ABOUT THE FUTURE FOLLOW AN ACADEMIC CAREER TO BE AN INDEPENDENT WORKER TO BE A RESEARCHER WORK AT “HOSPITAL DAS CLÍNICAS” SEE EACH PATIENT AS A PERSON AND NOT AS A DISEASE KNOW HOW TO MANAGE TIME HAVE DEEP KNOWLEDGE ABOUT A SUBJECT HAVE AN OVERALL VIEW OF MEDICINE TO BE A SURGEON WORK FOR THE RED CROSS DO MY BEST FOR A PATIENT HAVE A CLINIC

MALE GENDER 17 7 12 6 4 5 2 4 3 3 1 2 1 1 1 -

FEMALE GENDER 6 8 2 4 6 4 4 2 2 2 1 2 1 1 1 2 2

23 15 14 10 10 9 6 6 5 3 3 3 2 2 2 2 2 2

-

1

1

1 1 1 -

1 1 1 1

1 1 1 1 1 1 1

TOTAL

When asked about the difficulties they expect to face during the medical course, both gender groups answer that first of all they fear lack of time, once the course is too timeconsuming. In second place, the relationship with patients is mentioned as an expected difficulty. Thirdly, the excess of subject matters in school, followed by difficulty in learning all disciplines, the stress during the course, the selection exam for residency, the lack of didactics of faculty members, the choice for a specialty, among other difficulties are mentioned. One male student answered that he expects no difficulty at all.

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Table 6. Answers categorized as necessary personality traits for one becoming a good doctor, according to gender

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PERSONALITY TRAITS ALTRUISM BEING A HUMANE PERSON HARD-WORKING PERSON RESPONSIBILITY MODESTY PATIENCE HONESTY OPENNESS TO NEW ACQUIREMENTS BE FOND OF HUMAN BEINGS SENSITIVITY UNPREJUDICED PERSON ETHICS ASSURANCE CALMNESS PRUDENCE PRAISING LIFE EMOTIONAL STABILITY TEAMWORK SKILLS COURAGE ABILITY TO COMMUNICATE OBSERVATION CAPACITY CORDIALITY GOOD SENSE DISCIPLINE BE AWARE OF TAKING CARE OF LIVES BALANCE ABILITY TO FACE DIFFICULT SITUATIONS STEADINESS OPENNESS TO EXCHANGING IDEAS KNOWING HOW TO MANAGE TIME PRAGMATISM ABILITY TO DEAL WITH UNCERTAINTIES ABILITY TO RECOGNIZE THEIR OWN LIMITATIONS SINCERITY

MALE GENDER 29 7 6 2 2 2 1 2 2 3 2 3 2 1 2 1 1 1 1 1 1 1 1 -

FEMALE GENDER 25 5 3 6 5 3 4 2 2 4 1 1 1 1 1 2 1 1 1 1 1 1 1 1

TOTAL 54 12 9 8 7 5 5 4 4 4 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1

-

1

1

Most students believe that their medical routine will interfere with their private life, and there is no difference between genders in relation thereto. The arguments given are lack of time (59), doctor-patient relationship (11), social isolation (8), unpredictable time schedule (7), different comprehension of the world from laymen (4), adequate social conduct (2),

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parenthood delayed (2), and tiredness due to daily activities (1). Only four male freshmen answered that they would not like to marry a doctor. But the great majority (71.66%) told it would make no difference to them being married to a doctor, whilst 21.66% answered that they would like to marry a doctor. Despite the diversity of answers between both groups, no statistically significant differences between genders were found. The reasons most commonly mentioned for marrying someone with the same profession are: mutual comprehension; more issues to talk about; similar cultural level; and companionship. Among the reasons against marrying a doctor are: “the profile of my colleagues doesn’t match mine…”; “I’m competitive, ambitious and individualist”; “I want other subjects to talk about than medicine”; “both parents would be absent most of time, and children would be without proper care”; “I want to know different environments”. During the interview, the students were asked to describe five attributes a good doctor should have. Personality traits are mentioned by 91.66%, followed by professional skills (80%), good relationship with patients (60%), enjoying the profession (30%) and to be happy (1.66%). No statistical difference was ascertained between genders. All students believe that they potentially have these attributes (Tables 6, 7 and 8). From the 55 students who pointed out personality traits as a required attribute for one being a good doctor, 44 believe that this attribute cannot be taught. From the 48 students who pointed out professional qualification, twelve believe that the same cannot be taught. From the 36 students who pointed out a good relationship with patients, ten believe that the same cannot be taught. And finally, the only student who answered “to be happy” believes that this state of mind cannot be taught. Here, the statistical evaluation to ascertain the number of students who have mentioned a certain attribute as something that cannot be taught and the subsequent comparison between genders were made. No significant statistical difference was observed between genders in this regard. And closing interview results, professional qualification emerges — and this time as the most frequent answer (41 answers) — for both genders as the goal one should attain to become a successful doctor, followed by personality traits (19 answers). On the other hand, enjoying the profession (18) and establishing a good relationship with patients (17) — p=0.005 and p=0.045, respectively — were mentioned by a significantly greater number, from a statistical viewpoint, of female students in comparison to male students. Economical attainment, in turn, was mentioned by a significantly greater number, from a statistical viewpoint, of male students in comparison to female students as a successful medical career parameter (p=0.028). Social and personal life stability was answered by four students, and engaging in scientific activities was answered by only one student, with no difference between genders. In summary, the interview results show that for the greater number of questions no significant difference between both groups under analysis were found. Some small differences found indicate that a higher number of male students have identified themselves with other persons while choosing the medical career in comparison to female students. Furthermore, when questioned about what attributes a doctor should attain to be successful, the number of answers related to humanistic aspects of medicine given by male students was smaller while economic gains were stressed.

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Table 7. Answers categorized as good relationship with patients as a required characteristic for one being a good doctor, according to gender

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ANSWERS GOOD RELATIONSHIP WITH PATIENTS BE ATTENTIVE TO PATIENTS INSTILL CONFIDENCE IN PATIENTS RESPECT PATIENTS LISTEN TO PATIENTS SHOW INTEREST IN THE PATIENT’S INDIVIDUALITY KNOW HOW TO CONVINCE PATIENTS TO ADHERE TO TREATMENT TREAT EACH PATIENT AS A PERSON AND NOT AS AN ILLNESS. DO NOT GET INVOLVED TOO MUCH WITH PATIENTS KNOW HOW TO DEAL WITH DIFFERENT KINDS OF PATIENTS BE AT THE SAME LEVEL AS PATIENTS SEE A PATIENT AS A WHOLE EXPLAIN THE DISEASE AND THE TREATMENT TO EVERY PATIENT UNDERSTAND THE PATIENT ON A PSYCHOLOGICAL BASIS CORRECTLY INTERPRETE WHAT PATIENT SAYS HAVE EMPATHY WITH PATIENTS BE AN EXAMPLE FOR THE PATIENT WITHOUT BEING PERFECT FOLLOW THE PATIENT UNTIL THE END

MALE GENDER 14 3 6 1 -

FEMALE GENDER 11 4 1 1 2

-

1

1

-

1

1

-

1

1

-

1

1

-

1

1

-

1 1

1 1

-

1

1

-

1

1

1 1

-

1 1

1

-

1

1

-

1

TOTAL 25 7 7 2 2

Table 8. Answers categorized as professional qualification for one being a good doctor, according to gender PROFESSIONAL QUALIFICATION KNOWLEDGE COMPETENCE BEING ALWAYS UP-TO-DATE SKILLFULNESS EXPERIENCE GOOD EDUCATION INTELLIGENCE GOOD REASONING EXPEDITIOUS THINKING ABILITY TO LEARN

MALE GENDER 11 10 4 3 2 2 1 1 1 1

FEMALE GENDER 14 10 11 1 -

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TOTAL 25 20 15 4 2 2 1 1 1 1

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16PF Analysis of the Overall Profile of Primary Factors The overall profile of primary factors in male students is similar to that of female students, rp = 0.85, according to the statistical method proposed by the authors of the test.

Analysis of Raw Scores and Stens on Each Primary Factor Table 9 summarizes the results obtained by gender for each primary personality factor. Factors with statistically significant differences are specified below.

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Factor I – Sensitivity (Utilitarian x Sensitive) Factor I (Sensitivity) points to a significant difference between gender groups, thus indicating that there are more male students in the lower sten class (more rigid) than female students. Female students tend to be sensitive, delicate, painful, artistic, polite, sentimental, empathy-trusting, fanciful, feminine, demanding, impatient, and dependent and lack practical sense. Additionally, they ask for attention and assistance; do not tolerate rude persons and rough occupations; and disturb team work with frivolous unreal questions. Male students tend to be practical, objective, realistic, masculine, independent, responsible, skeptical before subjective cultural issues, firm, conceited, cynical, and vain. They are mostly concerned with objectivity and have a more utilitarian-viewpoint towards subjects. They place feelings in the background, and may face difficulties when dealing with situations demanding sensitivity. Factor M – Abstractedness (Grounded x Abstracted) Male students show higher Abstractedness (M) scores, which means that they tend to be informal, careless about daily simple matters, creative, imaginative, bohemian, and individualist. They are interested in “essential” things. They lose things and do not pay attention to time or practical details because they are more interested in thinking about their own ideas. Female students, in turn, tend to correctly perform feasible practical activities and go into details. They remain calm in emergency situations, are less utilitarian, more concrete and grounded. Factor Q2 – Self-Reliance (Group-Oriented x Self-Reliant) Male students show higher raw scores on Q2 Factor (Self-Reliance) than female students. No significant differences between both groups were found in relation to stens. The scores point to a possible tendency of male students following their own path without requiring social approval or admiration from those who share their environment. Female students, in turn, show a tendency to work and make decisions with other people because they need social approval and admiration from those who share their environment. No significant statistical difference was observed between genders in regard to other factors.

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Table 9. Sum of raw scores and stens on 16PF primary factors, according to gender (Mann-Whitney Test, α = 0.05; * significant difference)

PRIMARY FACTORS A – WARMTH C – EMOTIONAL STABILITY E – DOMINANCE F – LIVELINESS G – RULE-CONSCIOUSNESS H – SOCIAL BOLDNESS I – SENSITIVITY L – VIGILANCE M – ABSTRACTEDNESS N – PRIVATENESS O – APPREHENSION Q1 – OPENNESS TO CHANGE Q2 – SELF-RELIANCE Q3 – PERFECTIONISM Q4 – TENSION

SUM OF RAW SCORES IN MALE GENDER 884.00 933.00 996.50 906.00 816.50 969.00 594.50 975.00 1,107.50 965.00 895.50 976.00 1,073.50 858.00 942.50

SUM OF RAW SCORES IN FEMALE GENDER 946.00 897.00 833.50 924.00 1,013.50 861.00 1,235.50 855.00 722.50 865 934.50 854.00 756.50 972.00 887.50

P 0.645 0.789 0.226 0.894 0.143 0.424