Becoming Gods: Medical Training in Mexican Hospitals

By Vania Smith-Oka

Through rich ethnographic narrative, Becoming Gods examines how a cohort of doctors-in-training in the Mexican city of Puebla learn to become doctors. Smith-Oka draws from compelling fieldwork, ethnography, and interviews with interns, residents, and doctors that tell the story of how medical trainees learn to wield new tools, language, and technology and how their white coat, stethoscope, and newfound technical, linguistic, and sensory skills lend them an authority that they cultivate with each practice, transforming their sense of self. Becoming Gods illustrates the messy, complex, and nuanced nature of medical training, where trainees not only have to acquire a monumental number of skills but do so against a backdrop of strict hospital hierarchy and a crumbling national medical system that deeply shape who they are.

• Language: English
• Publisher: Rutgers University Press
• Release date: Jul 16, 2021
• ISBN: 9781978819672

Book preview

BECOMING GODS

MEDICAL ANTHROPOLOGY: HEALTH, INEQUALITY, AND SOCIAL JUSTICE

Series editor: Lenore Manderson

Books in the Medical Anthropology series are concerned with social patterns of and social responses to ill health, disease, and suffering, and how social exclusion and social justice shape health and healing outcomes. The series is designed to reflect the diversity of contemporary medical anthropological research and writing, and will offer scholars a forum to publish work that showcases the theoretical sophistication, methodological soundness, and ethnographic richness of the field.

Books in the series may include studies on the organization and movement of peoples, technologies, and treatments, how inequalities pattern access to these, and how individuals, communities and states respond to various assaults on wellbeing, including from illness, disaster, and violence.

For a list of all the titles in the series, please see the last page of the book.

BECOMING GODS

Medical Training in Mexican Hospitals

VANIA SMITH-OKA

RUTGERS UNIVERSITY PRESS

New Brunswick, Camden, and Newark, New Jersey, and London

Library of Congress Cataloging-in-Publication Data

Names: Smith-Oka, Vania, 1975– author.

Title: Becoming gods : medical training in Mexican hospitals / Vania Smith-Oka.

Description: New Brunswick, New Jersey : Rutgers University Press, [2021] | Series: Medical anthropology | Includes bibliographical references and index.

Identifiers: LCCN 2020043991 | ISBN 9781978819665 (hardcover) | ISBN 9781978819658 (paperback) | ISBN 9781978819672 (epub) | ISBN 9781978819689 (mobi) | ISBN 9781978819696 (pdf)

Subjects: LCSH: Interns (Medicine)—Mexico—Puebla de Zaragoza. | Medical education—Social aspects—Mexico—Puebla de Zaragoza. | Teaching hospitals—Mexico—Puebla de Zaragoza. | Medical anthropology— Mexico—Puebla de Zaragoza.

Classification: LCC R840 .S65 2021 | DDC 610.71/55097248—dc23

LC record available at https://lccn.loc.gov/2020043991

A British Cataloging-in-Publication record for this book is available from the British Library.

All photos by the author unless otherwise indicated.

Copyright © 2021 by Vania Smith-Oka

All rights reserved

No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is fair use as defined by U.S. copyright law.

The paper used in this publication meets the requirements of the American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992.

www.rutgersuniversitypress.org

Manufactured in the United States of America

For my parents, Pauline and Christopher

CONTENTS

Illustrations

Foreword by Lenore Manderson

Introduction: Medicine as an (Extra)Ordinary Social Commitment

1 Women Can’t Be Trauma Doctors, and Other Gendered Stories of Medicine

2 Doctors on the March: Punishment, Violence, and Protests

3 The Soul of the Hospital: Life as an Intern

4 Internalizing and Reproducing Violence

5 The Body Learns: Transforming Skills and Practice in Obstetrics Wards

Conclusion: Medicine as an Imperfect System

Acknowledgments

Glossary

Notes

References

Index

ILLUSTRATIONS

FIGURES

1. Map of the state and city of Puebla (illustrated by Charles Morse)

2. Popocatepetl volcano (photo by Pauline Smith)

3. Rooftop view of Puebla’s main cathedral

4. Main building for Hospital Piedad

5. Entrance for one of the city’s public hospitals

6. A list of tongue-in-cheek, rhyming mnemonics created by the interns

7. Minaret at Hospital Piedad. One doctor said, People always ask if the building is strong. I show them the tower. [It] was built almost 150 years ago. And it is still there.

8. Hospital passageway leading to doctors’ offices

9. Male interns resting in the residence

10. Interns from Hospital Piedad during a handover

11. Trainees and obstetricians during a cesarean delivery

TABLES

1. Paths to Medicine

FOREWORD

LENORE MANDERSON

Medical Anthropology: Health, Inequality and Social Justice aims to capture the diversity of contemporary medical anthropological research and writing. The beauty of ethnography is its capacity, through storytelling, to make sense of suffering as a social experience and to set it in context. Central to our focus in this series, therefore, is the way in which social structures, political-economic systems, and ideologies shape the likelihood and impact of infections, injuries, bodily ruptures and disease, chronic conditions and disability, treatment and care, social repair, and death.

Health and illness are social facts; the circumstances of the maintenance and loss of health are always and everywhere shaped by structural, local, and global relations. Social formations and relations, culture, economy, and political organization as much as ecology shape the variance of illness, disability, and disadvantage. The authors of the monographs in this series are concerned centrally with health and illness, healing practices, and access to care, but in each case they highlight the importance of such differences in context as expressed and experienced at individual, household, and wider levels: health risks and outcomes of social structure and household economy, for instance, health systems factors, and national and global politics and economics all shape people’s lives. In their accounts of health, inequality, and social justice, the authors move across social circumstances, health conditions, and geography, and their intersections and interactions, to demonstrate how individuals, communities, and states manage assaults on people’s health and well-being.

As medical anthropologists have long illustrated, the relationships of social context and health status are complex. In addressing these questions, the authors in this series showcase the theoretical sophistication, methodological rigor, and empirical richness of the field, while expanding a map of illness and social and institutional life to illustrate the effects of material conditions and social meanings in troubling and surprising ways. The books reflect medical anthropology as a constantly changing field of scholarship, drawing on research diversely in residential and virtual communities, in clinics and laboratories, and in emergency care and public health settings with service providers, individual healers, and households, with social bodies, human bodies, and biologies. Although medical anthropology once concentrated on systems of healing, particular diseases, and embodied experiences, today the field has expanded to include environmental disaster, war, science, technology, faith, gender-based violence, and forced migration. Curiosity about the body and its vicissitudes remains pivotal to our work, but our concerns are with the location of bodies in social life and with how social structures, temporal imperatives, and shifting exigencies shape life courses. This dynamic field reflects an ethics of the discipline to address these pressing issues of our time.

Globalization has contributed to and adds to the complexity of influences on health outcomes; it (re)produces social and economic relations that institutionalize poverty, unequal conditions of everyday life and work, and environments in which diseases increase or subside. Globalization has patterned the movement and relations of peoples, technologies, and knowledge, programs, and treatments; it shapes differences in health experience and outcomes across space; it informs and amplifies inequalities at both individual and country levels. Global forces and local inequalities compound and constantly weigh on individuals, impacting their physical and mental health, and their households and communities. At the same time, as the subtitle of this series indicates, we are concerned with questions of social exclusion and inclusion, social justice and repair, again both globally and in local settings. The books will challenge readers to reflect not only on sickness and suffering, deficit and despair, but also on resistance and restitution—on how people respond to injustices and evade the fault lines that might seem to predetermine life outcomes. The aim is to widen the frame within which we conceptualize embodiment and suffering.

---

The capacity to heal is revered everywhere, yet anthropology’s interest in the acquisition of the knowledge, skills, techniques, and arts of healing has been primarily for spiritual healers, including the revelation of their vocation, their initiation and induction, and their herbs and fetishes, appurtenances, and possessions. In these conventionally low-income settings, training takes place through apprenticeship to other experienced healers, midwives, shamans, and herbalists, in their own homes and in sacred dedicated spaces.

We have attended far less to the training of practitioners from any modality—Ayurveda, Traditional Chinese Medicine, Unani medicine, or cosmopolitan biomedicine—in professionalized, institutional settings. Yet the largest number of healers worldwide are biomedical doctors, nurses, and allied health professionals, trained in Western-style university medical schools and hospitals. In Becoming Gods: Medical Training in Mexican Hospitals, Vania Smith-Oka takes us, as readers, to two hospitals in the city of Puebla, southeast of Mexico City, and shows us how senior students of medicine become doctors in this setting.

Doctors become gods because they hold life and death in their hands. But the capacity to do this is learned. In Mexico, in their fifth year of training, medical students become hospital interns apprenticed to junior graduate doctors or residents. Sometimes also in the presence of established clinicians and specialists they study the art of clinical practice, and so earn the right to enter a pantheon. In the total institution of the hospital, on the lowest rungs of an insistent hierarchy, these trainees learn the codes of practice, the technologies and procedures, and the ideologies, attitudes, and values of being a doctor and becoming gods. Armed with the accoutrements of their practice—surgical scrubs, white coats, stethoscopes, and clipboards—they work impossibly long hours. They are sustained by the adrenaline of the excitement of medical emergencies and precarious lives and the challenges of acquiring the embodied hands-on skills of clinical assessment and care. At the same time, they are frustrated and demoralized by hospital bureaucracies and petty record keeping, run-down buildings, staff shortages, stock outages of drugs and other supplies, patient resistance, and the culpability and bullying of those who they are supposed to emulate.

In the shadows of Mexico’s political and economic instability, drug violence, and structural vulnerability, trainees learn the habitus of being doctors as these are shaped by structural and social factors, and as complicated within the hospitals by medical hierarchies, race, ethnicity, class, and gender. The latter stands out. Smith-Oka’s accounts of intentional, malicious violence against women are shocking: the harassment and victimization of female interns, the everyday sexism, and the physical, verbal, and emotional abuse of and unjustified obstetric interventions on female patients. The promised rewards of being a doctor allow trainees to stay the distance, as they constantly witness injustice, share in its perpetration, and rile against it.

Becoming Gods is provocative and deeply troubling. In Mexico—but also likely worldwide—we train young people to be doctors and to practice medicine without humility, care, or grace for people who are vulnerable and frightened, often desperately ill, and most likely too poor and too powerless to resist. Smith-Oka unfolds this account of doctor-making through rich ethnography and history, sensitivity and insight, and we are left to reflect on the small miracle: that a system of education and training that is often brutal and callous can produce so many doctors who are, despite it, deeply committed to the ethics of care.

BECOMING GODS

INTRODUCTION

Medicine as an (Extra)Ordinary Social Commitment

Those who are occupied in the restoration of health to others, by the joint exertion of skill and humanity, are above all the great of the earth. They even partake of divinity, since to preserve and renew is almost as noble as to create.

—Voltaire

[Patients] arrive here, and they see people wearing a white coat, and, I don’t know, they entrust their lives to them. It’s also cool they think that we are better than them, when in reality all we do is examine them and we know what medications or procedures are needed.… I believe [doctors] are like an extension of God’s hand.

—Ricardo, intern at Hospital Piedad

We have a bus accident coming in; a couple dozen patients will be arriving in one hour. The phone call came in at 1:30 A.M., reminding the interns doing an overnight shift at Hospital Piedad in the city of Puebla, Mexico that their time belonged to the hospital. They had just settled down on the two bunk beds in the hospital residence for what seemed like an uneventful night when the message about the accident was sent from the emergency room. A trailer on an eighteen-wheeler truck had come apart, veering across the midnight highway, and the bus struck it frontally. The bus driver was crushed in the wreckage—killed on impact. No one knew the extent of the passengers’ injuries.

Hoping to sleep for a while before the patients arrived, the interns curled up on bunks, two to a bed, stethoscopes and white coats hanging from bedposts. Megan (my research assistant) and I shared a lower bunk, our white coats over us as we tried to sleep. Less than two hours later we were buzzed awake by phone calls. Doctors, come to the ER now!

Grabbing their stethoscopes, glasses, and clipboards, the interns pulled their white coats over their sleep-rumpled scrubs and dashed along the dark hospital passages toward the brightly lit emergency room (ER).¹ The scrubs, white coats, clipboards, and able hands transformed them from sleep-deprived interns to competent superheroes and gods in the medical ward. I followed them, notebook and pen in hand, my arms trembling from the adrenaline rush. This event, though extraordinary to the victims of the accident and to the anthropologist, was ordinary for the medical personnel. It was one of a thousand harried learning moments, where the extraordinary nature of the tragedy was transformed into ordinary and normative.

It was 3:30 A.M. The air was tense, but under control. The clinicians had to work quickly. Gabriel, a very competent and thoughtful intern, was in triage with a young female patient. Israel and Diego filled out paperwork at the nurses’ station.² They were joined by Sebastián and Julieta. César, his hair in disarray, tensely clicked his pen as he strode by with a form in his hand. I hovered by them, feeling increasingly useless. I turned to Julieta and offered my help; she said, I’ll tell you in a minute how to fill out the [forms]. She then handed me an intake form and told me I could help her by writing down the patient’s name, age, family history, medical history, their symptoms, and reason for being here. She was familiar with this process, quickly noting the main details about the accident: Frontal crash, against a trailer that separated from the truck carrying it, and details about the patient’s impact during the crash—whether it was frontal or lateral and what parts of the bus they struck. In contrast to the practiced flow of her narrative, mine was choppy as I awkwardly wrote down patients’ answers to questions, uncertain of what was medically important to include and what was not.

Because this was a highway accident, it fell under the jurisdiction of the Ministerio Público, the national jurisprudence and prosecutorial ministry. In addition to all the paperwork the interns were expected to fill out for each patient, they also had to complete Ministerio forms reporting the details of the accident, which would be used for insurance purposes. After they filled out the many forms, the doctor on call signed each one. Some interns whose patients had already been released took advantage to catch a few minutes of sleep back at the residence, to the dismay of those who were still waiting for results from X-rays and other medical tests. At 7:00 A.M., as the last patient was rolled away by orderlies, the interns staggered back to the residence to shower and begin their day with patients, examinations, and paperwork.

For the interns, who are students in their fifth year of medical training, this was what I term an extraordinary, ordinary night. It was ordinary because every day at the hospital they had to deal with patients, doctors, paperwork, and technology, and to do so with little to no sleep. The bulk of their training came from the ordinary minutiae of medical care. The practice of such minutiae slowly transformed them from hesitant neophyte doctors, who barely knew how to do basic procedures such as suturing or intake forms, into experienced physicians who could confidently navigate hospital spaces and patient bodies. But the night was also extraordinary. Bus accidents were not a regular part of the interns’ routine or even of their training, and they had to rapidly figure out what they needed to do and do it well. The extraordinary occurred rarely, but the halls of medicine are awash with such stories. These events form the basis of prevailing fears and anxiety, essentially shaping how medicine is learned. And yet it is in the ordinary where medical transformation is most profound and where its effect can be most impactful on patient lives. Interns’ responses to both the extraordinary and the ordinary become yardsticks to gauge their commitment to medicine.

In this book, I employ this ordinary–extraordinary heuristic to explain how medical knowledge, skills, and attitudes are transmitted within hospital spaces, how sometimes things that should be ordinary (like vaginal birth) become extraordinary, and how some practices that should be extraordinary (like bullying or obstetric violence) become ordinary. I explore how medical students in Mexico transform into fledgling physicians over their year-long internship, acquiring a medical self. Within this dynamic setting, interns develop a medical self in the ordinary spaces and experiences—navigating a medical ward, sleeping few hours, learning to speak with patients from different backgrounds, as well as with doctors, nurses, and colleagues, presenting cases, embodying medical and social values, and handling new equipment—as well as in the extraordinary—learning to manage stress when a patient goes into cardiac arrest, identifying themselves with the stories of struggling doctors elsewhere, figuring out whether to empathize or not with a patient who arrives with a stillbirth pregnancy, or treating bus accident patients. I draw from Joseph O’Donnell’s (2015) categories of what an anthropologist observes in a hospital ethnography, paying attention to what people do as well as to which artifacts are used (e.g., tools, paperwork, pictures, spatial layout), the symbolism attached to these, and the assumptions underlying people’s beliefs and behaviors (the unconscious and taken for granted ways by which things are done).

Here, I follow the medical lives of thirty-six interns in two hospitals in the city of Puebla as they traverse their internship. I tell their stories of awareness, exhaustion, joy, and frustration. I also include the voices of their supervisors—the surgeons, obstetricians, and emergency room doctors who evaluate and teach them on their journey. These voices are most evident during formal casos clínicos (case presentations or grand rounds), an interactive event where trainees present a clinical case to their medical colleagues and discuss medical techniques, skills, differential diagnoses, and outcomes. These presentations sometimes take place in conjunction with an attending physician or resident. Residents, while still trainees themselves, are significant participants in the interns’ transformation, and their voices are audible in this book. While interns are medical students, residents have completed their basic requirements for general practice and have passed a rigorous national examination before being accepted into a residency program.³ They are above the interns on the medical hierarchy.

The social, economic, and racial distinctions between various groups in Mexico are very sharp and have been created by the historical processes that form the conditions for present-day mechanisms of exclusion. I explore how medical practice differs in private and public hospitals, which have vastly different facilities and patient loads, how the space constricts or encourages gendered ways of practice, and how men and women learn to navigate these sometimes hostile and violent spaces and interactions in different ways. Though much research has been done on medical socialization, I raise new questions. How is seemingly invisible knowledge about the practice of medicine transmitted to trainees? How does the (extra)ordinary form their medical self? How are physicians trained to think in certain ways about their patients? How do trainees cultivate their body to become expert? How does violence within and outside of the hospital impact the medical self?

PRACTICING MEDICINE WITHIN INTERSECTIONS OF RACE, COLOR, CLASS, AND GENDER

This book is about transformation—of medical students into medical selves. Though biomedicine is a global profession, it is taught, practiced, and experienced in local contexts (Good 1995b). I explain how interns embody a paradox. They are doctors in training, learning to wield new tools, language, and technology, sometimes with mixed results; they are exhausted from long work hours and little sleep; they are at the bottom of the medical hierarchy, doing the intensive, less recognized labor necessary for medical care. They do not feel like experts, yet from the moment they begin medical school they are referred to as doctor, by both professors and patients alike. Their white coat, stethoscope, and newfound technical, linguistic, and sensory skills (Van Drie 2013) lend them an authority that they cultivate with each practice, transforming their sense of self. They help save patients’ lives, deliver babies, and attend to victims of highway accidents. They sometimes do feel like experts. What I emphasize is the messy, complex, and nuanced nature of transformation, where interns not only have to acquire a monumental number of skills but do so against a backdrop of strict medical hierarchy within the hospital and a crumbling national medical system that inflicts violence upon them. This enskilment is fully immersive and caught in the incessant flow of everyday life (Pálsson 1994, 901)—it demands that interns be actively engaged with their environment, simultaneously learning and doing (Ingold 2000) rather than solely internalizing a stock of knowledge.

I explore the tensions and contradictions present in this transformation. I draw on frameworks of embodied learning (Downey 2010; Gieser 2008; Harris 2016; Prentice 2013) and of sensory enskilment in training (Pálsson 1994; Rose 1999; Van Dongen and Elema 2001; Van Drie 2013) to explain the fine-grained ways by which medical trainees learn new skills, practices, and bodily ways of attuning to/with the world around them (Csordas 1993, 138) as they inhabit their medical selves. Drawing on rich literature on reproduction, race, and gender (Andaya 2019; Davis 2019a; Gálvez 2019; Dixon 2015), I also address how medical transformation is conditioned by the broader political economy, such as Mexico’s deep violence—structural, gender-based, obstetric, and caused by drug cartels. I attend especially to how the intersections and imbrication of class, gender, skin color, and ethnicity are acquired, enacted, reproduced, and perpetuated through medical bodies.

Mexico is a middle-income country with significant resource distribution issues in its health care: some medical centers are bereft of even basic supplies while others are extremely luxurious. Based upon ethnographic work in regional urban Mexico, I show how in the seemingly mundane practice of medicine, the most significant transformation takes place.

During most of the Mexican colonial period, doctors came from the Mexican upper classes and were required to be of pure (i.e., Spanish) ancestry. The patients and bodies on whom they practiced their skills, however, were primarily the impoverished and Indigenous (descended from the original inhabitants) populations who had little choice about how their bodies were treated by doctors.⁴ Hospitals are colonial institutions that are sites for patient care and treatment while simultaneously being used for efforts at hygienic order, indoctrination, and civilizing projects (Anderson 2009; Zaman 2005). In these settings one finds significant historically based and prevalent class-based, gendered, and race-based distinctions. As Beatriz Reyes-Foster (2016; 2018) stated, aspects such as power, hierarchy, and inequality are very real within Mexican hospital wards, especially in public institutions, reflecting a persistent coloniality that maintains colonial relationships long after colonization ends.

To speak of race in Mexico is considered impolite. Instead, society takes great pains to deny, twist, and conceal the reality of racism and discrimination (Dulitzky 2005). Race in Mexico exists along a malleable social spectrum that incorporates color, class, power, and region (Braff 2013). Regardless of skin color, most of the population self-identifies as mestizo (mixture of white and Indigenous), though there are also Indigenous, Afro-Mexican, Asian, and white populations. The historical formal racialized structure of castes created during the colonial period was eventually abolished after independence. The country’s leaders, aided by anthropologists (Ruiz 2001), promoted assimilationist racism (Gall 2004, 240) through a mestizo ideology. The assumption is that there is no racial discrimination because everyone belongs to the same race (Oboler and Dzidzienyo 2005).

However, the ambiguity of the concept of mestizo—which can range from more Indigenous to more European—hides profound discrimination (Ruiz 2001), which usually operates through a tight weave of social class and skin color (Aguilar 2013). People tend to, instead, euphemistically employ the term cultura when they talk about race (Ruiz 2001), assuming cultura to be a gentler word than race; however, as I will describe in future chapters, cultura is used in deeply discriminatory fashion against problematic patients. This pigmentocracy (Telles, Flores, and Urrea-Giraldo 2015) socially stratifies based on color and is underlined by racial whiteness as an advantage (Nutini 1997), whereby whiteness is created through social processes of acquiring social or economic capital, and indexed by engaging in practices such as using reproductive technologies (Braff 2013; Roberts 2012). Like in Ugo Edu’s (2019) work on racial aesthetics in Brazil, Mexico’s race/class social ladder places at the top the populations who are perceived as whiter, more beautiful, and wealthier and at the bottom those perceived as darker, uglier, and more impoverished (see also Saldaña-Tejeda and Wade 2019).

This pigmentocracy is visible in current biomedical practice. Most present-day doctors continue to be drawn from middle-class and upper-class populations while the patients in public hospitals (where the bulk of medical training takes place) come from darker-skinned, poorer, and more disenfranchised populations. Mexico’s socioeconomic racism becomes highly visible in contexts where things are at stake—such as in hospital wards where physician and patient interactions are fraught with the ever-present fear of risk of death. In hospital halls, you can hear some of the most unabashed criticism and racialized aesthetics against those people, whoever they may be—teenage mothers, Indigenous people from the sierras, or wily patients (Bridges 2011, 227) who are seen to game the system by using more resources (medications, doctor hours, medical locations, etc.) than people believe they should or who do not follow the doctors’ medical common sense. For some doctors, knowing a patient’s socioeconomic background is a shorthand to understanding where they had been treated previously—whether by a private doctor, a hospital, an auxiliary medical center, or a pharmacy—rather than to understanding their patients’ lived experiences. Mexican hospitals become key places to unpack the enactment of institutional logic on the bodies of all actors involved.

TRANSFORMATIONS OF THE SELF

Like Seth Holmes, Angela Jenks, and Scott Stonington (2011, 106), I am fascinated by the question of What kinds of people are formed through contemporary processes of clinical training? This is a key question because a lengthy process like medical training that takes place in total institutions (Goffman 1961; Good 1994) like hospitals is not just about acquiring skills and knowledge, but is also about becoming something new: students become healers, experts, caregivers, decision-makers. Elizabeth Roberts (2016, 216) urged anthropologists to pay attention to the material realities of the practice of medicine, the broader political economy that shapes these practices, and how they both produce certain kinds of deities in certain places and times. I am curious to understand how people behave when they are trained to have power over life and death. How is this process transformational to the interns’ selves and identities?

Several anthropologists have focused on the way that biomedicine alienates patients’ self from their body, making the person (and their illness) into an object (such as a patient or a case) able to be accessed by the medical gaze (Carpenter-Song 2011; Good 1994; Good and Good 1989; Young 1997). Mary-Jo and Byron Good (1989, 308) stated that these boundaries are also significant as medical students develop a professional self, wherein they must reorganize boundaries between themselves and patients, and struggle to resist being swallowed up by medicine. As Tanya Luhrmann (2001, 533) suggested, the self is a cognitive schema and a bounded collection of conceptions and ideas that allow an individual to experience and think with the world. This sense of self is an introspective experience of I and exists in multiple ways: as one’s relation to the physical environment, as one’s interpersonal interactions, as something extended through time (our past selves and the selves we will become), as private (where we all have a sense of self that others cannot see), and as conceptual (consisting of the wealth of concepts, features, and traits that comprise oneself) (Luhrmann 2001).

I employ Rebecca Allahyari’s (2000, 4) concept of moral selving, which she defined as the work of creating oneself as a more virtuous, and often more spiritual, person, in order to understand the process of medical selving—which I define as the work of totally transforming oneself and not just a situated identity. A medical self is created through both deliberate and passive forces wherein trainees must decide what kind of a medical self they hope to create through their practice of medicine (see Allahyari 1996 for a deeper analysis of moral selving). It is