Student notes on an extract from Stephen A. Hoffman’s Under the Ether Dome


“You hardly realize you are being changed and yet you are.”

‘Under The Ether Dome’ reveals many different issues that the author personally experienced in his journey to becoming an intern at Massachusetts General Hospital. Hoffmann highlights how internship, for him, began the moment he entered into medical school. He emphasizes the ‘changes’ that occur, most importantly in attitudes and beliefs to each student beginning their first medical year.

As a first year medical student myself, Hoffmann’s first chapter both amused and surprised me. He describes how the “transformation had already begun” as he sat down for his first lecture in the large amphitheatre at Harvard University. He reveals how he believed “med school, I was sure, would be a grind.” Yet, as the year progressed he highlights how he also found that “it was also remarkably enjoyable.” When I sat down for my first lecture in Medicine at Trinity College Dublin, it really wasn’t what I had expected either. One month on, and I still don’t feel “transformed” as Hoffmann described, yet then again, he highlights how it is “more felt than seen, and it progresses almost imperceptibly.”

The author shows the impact that Harvard University’s prestige and fame had on him. He highlights how “the shadow of history” lay heavily upon both himself and his classmates. The many famous physicians such as Walter B. Cannon and William Best that also began their careers in Harvard created a sense of intimidation within Hoffmann, I believe, that he was challenged to live up to these men.

“Would we do justice to the long line of distinguished doctors who preceded us?”

Like Hoffmann, I too feel the intimidation and pressure of being a medical student in a prestigious college. When I accepted my place in Medicine in Trinity College Dublin, I knew it was going to be nothing less than life-changing for me. The honour of being taught by some of the most highly regarded lecturers in the world, as well as having state of the art anatomy and physiology laboratories to learn in has a huge impact on each student in Medicine here in Trinity I believe.

Hoffmann highlights the challenge he felt of following in the footsteps of Walter B. Cannon in Harvard University, whereas I feel there is a challenge within many medical students I know to also be as accomplished as some of Trinity’s most famous alumni. I believe the author’s first impressions of medical school are endearing and interesting to read as they can be felt by the reader, particularly a first year medical student, that reads his first chapter.

Hoffmann’s honesty is what I believe I relate to the most. His use of symbols to highlight the enormity of what his first medical year entailed for him appeals to me greatly. He describes how the “panoramic view was breathtaking” as he discusses the first year curriculum that he studied. His “panoramic view” highlights how he is not just living his dream but also enjoying the diversity of the subject as well as how “breathtaking” the workload of his first medical year was.

Personally, I enjoyed Hoffmann’s humour and comic relief throughout his opening chapter. “We also took anatomy lab. On the first day, our instructor fainted. Apparently he had never taught the course before.” The author’s account of his first anatomy lab reveals how this comical occasion, and the many other anatomy labs to follow, were his way of enjoying the “breathtaking” workload of anatomy. He shows how each student felt the tension ease in these labs as “the fine points of dissection eluded almost all of us.” I admire Hoffmann’s honesty in describing the “hopelessly comic” scene of events that occurred in anatomy even though the impact of what each lab entailed was always felt too.

“Once we began the abdominal dissection, we discovered our cadaver was flawed.”

Hoffmann’s account of the anatomy lab also creates a sense that the immensity of his career fell upon him when he discovered the many tumours that his cadaver had. He uses the gentle word “flawed” even though the impact of this experience was huge for him as he describes how it had taken him “beyond the realm of the abstract”.

Another aspect of Hoffmann’s first chapter that surprised me was his thoughts on his Medicine and Literature course. He reveals how he thought it “sounded unlikely indeed for a medical school curriculum,” which was surprising as this was how I also felt as I tried to pick my Humanities module this year. Like the author, the title ‘Medicine and Literature’ also lured me into choosing the module, I was unsure of what to expect yet my curiosity of what this broad module entailed made me choose it. “There was no overarching thesis to the course, no critical perspective imposed on us.” The author reveals how he was enthralled by the contrasting nature of this course in comparison to his lectures in anatomy and physiology.

“Literature celebrated this uncertainty, while medicine often seemed to abhor it.”

The author’s opinions throughout the chapter are both insightful and unexpected. Hoffmann reveals how he believes “physicians are always at risk of taking themselves too seriously.” This generalisation provides the reader with a view which is then contrasted with Hoffmann’s own experience in the OR for the first time. The author’s enthusiasm is endearing in his account of the events that took place that morning. He wanted to be professional, confident, careful and most of all, he wanted to feel a sense of belonging within the OR medical team, yet he couldn’t. ““Contaminated myself, didn’t I?”” As the author “hoped to avoid wrongdoing” during the operation, Hoffmann’s feelings of irritation, humility and inadequacy are clearly felt in this scene.

Yet, as Hoffmann goes on to recount his experiences of his second medical year, the mood of the chapter, I believe, changes. Hoffmann reveals how it was the “most intense segment of our medical school career.” I believe his sense of adequacy and feelings of belonging are felt more in his second year than his first year. “Running gave me an invaluable sense of continuity and belonging.” Hoffmann’s language also reveals his more positive outlook in second year. He uses words such as “wonderful” a number of times throughout the chapter, for example “wonderful runs” and “enjoyed remarkable successes.”

I also feel that Hoffmann gained a sense of freedom as he continued throughout his second year where he reveals how “finally we were turned loose.” Again, Hoffmann’s humorous encounters provide the reader with a sense of how the author’s eagerness to do his best for his patients and live up to the prestige of Harvard impacted on him as a medical student. I enjoyed the author’s account of his consultation with the patient from Boston that had “hat disease.” The tutor’s reaction was also even more amusing. ““Did you ask him where he ‘paks his cah’?” the tutor asked. “It’s heart disease, not hat disease he has!””
In Hoffmann’s final two years of medical school, I believe the themes revealed throughout the beginning of the chapter in first and second year are again interestingly repeated in quite a similar way.

“Almost overnight we went from onlookers to participants in the workup of patients.”

I believe Hoffmann’s honest account of his experiences on the wards of the hospital are what makes his first chapter so enthralling to read. Again, just like the first time he walked into the OR in first year, he felt daunted and nervous carrying out his first ever suture on a patient. The feeling of inadequacy and humility underlies his experience of suturing his patient’s head wound.

Hoffmann also continues to ask both the reader and himself many questions, just as he did in first year as he questioned the many equations of physiology that he had memorized by heart. “What was I doing violating their trust?” I believe this line highlights how strongly he feels the patient’s needs must be considered above his own need to learn how to correctly suture a wound. He bombards the reader with ethical questions that are very difficult to answer. “Was I prepared to commit errors in the quest to become a capable physician?” These questions are an important aspect to the opening chapter in my opinion. They highlight how he questions not only the reader’s beliefs but also his own character and ability to be a good doctor.

I also feel that it is important to highlight the comparison in attitudes that the intern in the suture scene and the OR resident that he encountered in first year had towards him as a medical student. The intern gave him a look that was “confident and sad,” “as if he were trying to say, go ahead everything will be all right.” In contrast, the OR resident he met “bellowed” at him. He made Hoffmann feel humiliated in front of the OR team by asking him ““What are you doing?” “Get up here!””

I believe that Hoffmann’s first suture was a major landmark in his medical career. He reveals this by saying “I was now in the pilot seat, a doctor.” Yet, although Hoffmann was nervous, he was also clearly elated to be given the opportunity to further his medical experience- “bit by bit my confidence grew.”

The similarity of his experiences in both his first and final years of medical school continue as he reveals the more serious side to his time on the wards. He reveals his thoughts on how “medicine is not a game. We were no longer in the realm of the textbook.” It is clear from this line that the comical antics that occurred in the anatomy labs in first year contrast greatly to the extent of maturity that he has gained since then.

Hoffmann highlights how in his final years they “were under tremendous pressure to perform,” just like they were when they first started in medical school. In first year, Hoffmann was expected to live up to the prestige of Harvard whereas now, in his final years, he was expected to rise to any challenge that was brought before him along the wards of the hospital. Yet, in contrast to his feelings of doubt and fear in first year, Hoffmann reveals how he felt more capable and confident in his final years. “I came to feel more like a doctor.”

Hoffmann’s first chapter gives the reader an outlet to consider the many ethical dilemmas that a medical student encounters throughout their time at medical school. I liked how Hoffmann provided the reader with a very personal view of his own experience of ethical issues and his beliefs. His gratitude and respect towards his patients makes him an extremely likeable character in my opinion. “Our learning to be physicians ultimately derives from the charity of patients.”
The honesty displayed throughout the opening chapter of ‘Under the Ether Dome’ is what made me want to read Hoffmann’s other chapters. The language and changing moods expressed as he moved from one medical year to the next was insightful for me as a first year medical student. I believe Hoffmann’s book not only appeals to medical students, but also to every healthcare professional. Hoffmann makes his readers reflect on their own beliefs on diverse ethical issues that most affect their relationship with the patient. Yet in saying this, the author does not impose his own opinions on the reader, he instead effectively provides an outlet of reflection to any reader that has had similar experiences to him.

“My life seemed like an early series of beginnings and leave–takings.”


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