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Us and Them

I am a second-year medical student—an older medical student, married, with a five-year-old boy and a baby. In medical school, people like me are called nontraditional—a euphemism for peculiar, different.

Today a group of my classmates and I have gathered, wearing our white coats, at a basketball court in Barrio Bélgica, in the south of Puerto Rico, where I’m completing my first two years of medical school. We’re here to visit with some of the local people as part of our Community Medicine course. This meeting is supposed to give us practice at basic care—talking with people, measuring their blood pressure, listening to heartbeats.

I greet my classmates, but few respond. In the two years we’ve known one another, this has become a pattern. It doesn’t surprise me anymore, but I know it’s significant.

Looking across the court at the people of Barrio Bélgica, my classmates seem nervous and aloof. Most of their parents are doctors or lawyers, people of wealth who seldom come into contact with people of different classes or backgrounds from theirs. (None of my peers have actually said this, but it’s an assumption I make. Growing up, I never crossed paths with people like them unless my family and I went to see a doctor or watch a movie.)

I’m embarrassed to admit it, but I dislike many of my classmates. Or maybe I resent what they represent to me. I grew up in a barrio like this, Barrio Bajuras, in the mountains of Vega Alta, west of San Juan. To me, in this moment, it feels as though “they” are rejecting “us” once more.

Part of me wishes I belonged on my classmates’ side of the court, but I don’t feel that I do. That feeling, too, troubles me.

I’m keenly aware of what I perceive as my peers’ weaknesses, and I judge them intensely. Some mention Porsches and big houses with swimming pools as their reason for seeking a medical degree. They dismiss conversations with elderly patients as something insignificant to be dispatched as briefly as possible.

My family never had much while I was growing up, so I understand the craving for material goods and security. But I also know that people like my family members and the neighbors at this basketball court need doctors whose first priority is to recognize and understand their complexity. They need physicians for whom giving health care is more than just a family tradition linked to status, power and acquisition.

Barrio Bélgica might be foreign to the other students, but not to me, I tell myself. This feels like my superpower, what sets me apart, but really it’s just something I keep repeating so that I, too, feel that I belong.

I walk to the Barrio Bélgica side and introduce myself, offering my hand to each person in turn. They, too, seem guarded.

Are they afraid of me? I wonder in amazement. I’m one of them!

Only right now, I’m not. With this white coat on, I’ve suddenly become someone else—I’m not yet sure who.

The white coat makes me look no different from my classmates. I feel like taking it off, but it’s too late. Now the neighbors seem suspicious of us all, in the same way that medical school covertly teaches us to be suspicious of them. We are made wary of patients seeking something from us—pain medicine, disability papers, even lawsuits. In a system that divides us into providers and clients, into the knowledgeable and the ignorant, into those with their hands on the blades, with the power of amputating limbs, and those who’ll lose their feet, it seems that we’re all meant to fear each other.

The first person I talk to is a middle-aged man named Nelson.

“I was in college once, and I was great in mathematics,” he reminisces. This revelation resonates with me. To this day, I use my knowledge of physics and mathematics as my “safe place” when surrounded by other white coats and my own insecurity. Being good at math means that I’m unquestionably smart: I should be here.

“…two daughters and no longer married,” Nelson continues. His voice is strong, but tense. “God is important,” he continues, holding up an index finger for emphasis. “For if His spirit leaves your body, you are nothing.”

To a nonreligious person like me, Nelson’s comment feels somewhat threatening, as if I’m at risk of being outed. But I need to build a bond with him, however transient. Otherwise, why am I here?

Nelson isn’t working anymore, because “the government gives me what I need.” He worked long enough, and now he just wants “to flow.” He adds, “People only work to earn money, not because they love what they do, and that’s a mistake.”

The others should hear this, I think. Then I realize that his words are aimed at me. Looking at my white coat, he sees only the status it confers—and the threat, perhaps, of all that I might not understand or even reject about him.

I’ve often heard people say that medical training takes away a part of you, without specifying what. As I’ve learned, it doesn’t just take away your confidence in your ability to absorb overwhelming amounts of information, or your sense of empathy. Medical training also takes away the intuitive knowledge that you shouldn’t have to conform—to be a specific kind of student or person—in order to become a doctor.

That’s been my experience, at least: a constant underlying sense that who I am, and where I’ve come from, does not fit the expected standard. There’s often a tension, too, in other’s assumptions about who I am, based on where I come from, the color of my skin, my age or even, as I move forward, the school I’m attending on my way to becoming a doctor.

What Nelson is telling me is that he doesn’t need my help—that Iris-with-the-white-coat has as much to learn from him as he does from me.

Nelson reminds me of my father, a loud, barrio-raised, working-class, street-smart man who could smell fear a mile away. Seeing me as an older medical student, with more life experiences than my peers, navigating our differing languages and socioeconomic experiences, does Nelson intuit my unease as I attempt to position myself between two very different worlds? Is he telling me that I should stop pretending that he and I are equals? After all, I have chosen to wear this uniform that sets us apart.

The question is, if I succeed at crossing this boundary between the place I come from and my future role as a doctor, who will I become?

I want to inhabit a middle space—a place from which I can move forward into my future identity as a doctor, but that also allows me a continued sensitivity to the gap that my white coat creates between Nelson and me. The gap that erases his complexity and mine—that makes us afraid of each other.

I do think that my best chance at making a difference in people’s lives will come by inhabiting that middle space.

Empathy presupposes that you can put your feet inside someone else’s shoes and experience what that feels like. But to do that, I’m starting to believe, you must first take off not only your own shoes but also—daringly—your white coat.

Iris Mónica Vargas, a Puerto Rican-born writer/poet with graduate degrees in physics and science writing, is currently a third-year medical student at Saint James School of Medicine. Her work has appeared in Latin American Literature Today and other national and international publications. She has written three books of poetry, one of which, El libro azul (The blue book), received a PEN Puerto Rico International Award (HM) in 2018. “I’m a teetotaler. Not as an activist or anything that dramatic; I just don’t like the taste of alcohol, so when I feel sad or dejected, I turn to the nearest bookstore or library instead. I’m always seeking to understand what happens around me, what I’m thinking and where those thoughts arise from as a means of survival. I guess that’s why I write.”

Comments

8 thoughts on “Us and Them”

  1. Such an important piece. You write with such insight and clarity; and you end by making the connection between EDI and empathy. Empathy is such a powerful and healing skill. What you write is relevant not only to the medical profession but to so many other professions and organizations. It ought to be on the curriculum!

    1. Henry Schneiderman

      Among its other virtues, this report is a witness to idealism and compassion. I agree with the other comments and would add two pieces of advice: first, never accept the (often unspoken but unmistakable) criticism that hand-holding is inimical to bioscientific excellence; rather, they go hand in hand. Second, I recommend Tolstoy’s Death of Ivan Ilyich as a most potent story including about why your values are sound and why excessive materialism serves neither doctor nor patients.

  2. thank you for putting words to such complex emotions and situations. how we get to the “we” belong together is worthy of all of the effort. Please keep writing dear heart.

  3. Dear Iris,
    The fact that you are already acutely aware of the chasms a white coat can create between a doctor and patient shows that you have already surpassed the boundaries of that symbolism. Your empathy will always get through and your medical career will thrive. Thank you for sharing.
    Andrea Karsh

  4. Med school constantly provokes an identity crisis, but I hope you know your life experiences and perspective are invaluable for relating to people of all kinds. You will be a fantastic physician!

  5. Thanks for sharing this. Your classmates seem to represent the worst path doctors can take. The snobbery. The elitism. I’m glad you’re out there, the kind of humane doctor we all need.

    1. I never comment, until now. Beautiful article, and beautiful person that you are. I’d much rather have you for a doctor than the other students. I trust they will mature too.

  6. Dear Iris
    I shared a similar journey, Puerto Rican and grew up in New York’s El Barrio, went to Med school at 35 with two kids and a lot of misgivings.
    Time has been good to me and I have had a rich and rewarding medical career as I am sure that you will. You have already found that middle ground and you will do great things for your family and your community. Keep moving forward with your head held high. You have every right to be there!

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