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Korean J Med Educ > Volume 28(2); 2016 > Article
Hwang, Kim, Kim, and Hwang: Analysis of medical student’s book reports on Cronin’s The Citadel: would young doctors give up ideals for prestige and wealth?

Abstract

Purpose:

The purpose of this study is to find what medical students think the reward for their future work should be and whether they would keep their ideals or abandon them for prestige and wealth by analyzing the book reports of Cronin’s The Citadel.

Methods:

Participants were 50 medical students of junior class. A month before the classroom lecture, the book and digital video disk were provided. Students had discussions in groups of seven and wrote book reports which include answers of three questions.

Results:

Regarding what should be the reward for the medical doctor, two-thirds of students (66.7%) answered with spiritual compensation, while one-third (33.3%) chose material reward. In the situation presented to Manson, three-fifths (60.0%) answered they would keep their ideals (idealist), while the remaining two-fifths (40.0%) decided they would abandon them. Less than one-third of students (30.0%) answered they would reveal the corruptions of the doctor’s society, while two-thirds (64.0%) would not.

Conclusion:

The larger number of idealists who prefer spiritual reward rather than a material reward represents the innocence of youth as in portrayed in The Citadel.

Introduction

As Dr. Cabot has warned in 1918, it has been granted that “Among the rewards which the doctor cannot expect is wealth [1].”
Nowadays insurers, administrators and other health care providers have begun to challenge the position of the medical profession in the health care market and medicine did not escape public censure and criticism throughout 1900 to 1950, the first golden age [2]. Among the popular books of the time, The Citadel (1938) dealt with the idea that money can and will corrupt an idealistic physician [3].
A 24-year-old idealistic medical doctor, Andrew Manson, took up a position in a small Welsh mining town and solved the town’s problem of typhoid by blowing up the sewer. When moved to London, disillusioned by bureaucracy, he was tempted by society practice and slowly abandons his ideals in exchange for prestige and wealth.
As a medical educator and as medical students, we would like to discover what medical students think should be the reward for the medical doctor and whether they would keep the ideals or abandon them in exchange for the prestige and wealth promised to Dr. Manson in the novel.
The purpose of this study is to find what medical students think should be the reward for their future work and whether they would keep their ideals or abandon them for prestige and wealth by analyzing the book reports of Cronin’s The Citadel.

Subjects and methods

Participants were 50 medical students in their junior class (second year of a 4-year course). The mean age was 27.4±2.3 years. This study was adhered to the principles outlined in the Declaration of Helsinki.
Korean translation of Cronin’s The Citadel and a copy of the digital video disk (DVD) of The Citadel (1938, director: King Vidor, actors: Robert Donat and Rosalind Russell) were provided to the individual students at 1 month and 2 weeks before the forum respectively.
They were asked to have a discussion in groups of seven on the themes. Students representing each of their group presented their opinion in an open forum. After the forum, they were asked to do a reflective self-analysis and book review considering the key themes of the novel.
In their analysis of Cronin’s The Citadel, the following questions were asked to be included:
  • (1) What should be the reward for the medical doctor?

  • (2) If I were in the same situation as Dr. Manson, would I keep my ideals or abandon my ideals in exchange for prestige and wealth? (idealism or realism)

  • (3) Do I have the courage to reveal the corruptions the medical doctor’s society as Dr. Cronin did?

Factors that might have affected their decisions, such as age, gender, marital status, number of family members, and volunteer work hours were also analysed. We abstracted the odds ratio and 95% confidence intervals. The statistical analysis was performed with Microsoft EXCEL 2010 (Microsoft Co., Redmond, USA).

Results

The results of questionnaires were as follows:

1. What should be the reward for the medical doctor?

Among the 50 respondents, 35 had just one answer, while 14 wrote two answers, meaning a total of 63 answers were collected. Among them, 42 (66.7%) included a form of spiritual compensation, while 21 (33.3%) were material reward. The spiritual compensation included honor (22, 35%), approval (7, 11.1%), satisfaction (6, 9.5%), respect (4, 6.3%), and happiness (3, 4.8%). Material rewards included wealth (17, 27%) and prestige (4, 6.3%) (Table 1).
There was no significant difference in age groups, gender, number of family member, or voluntary work hours for the reward for the medical doctor.

2. If I were in the same situation as Dr. Manson, would I keep my ideals or abandon my ideals in exchange for prestige and wealth? (idealism or realism)

Among the 50 respondents, 36 had just one answer, while 12 wrote two answers, meaning 54 answers were available. Thirty-six (60.0%) answered they would keep their ideals (idealist), while 24 (40.0%) would adapt themselves or pursue prestige and wealth (realist). The realists pursued reality (13, 21.7%), wealth (6, 10.0%), and prestige (5, 8.3%) (Table 1).
There was no significant difference in age groups, gender, number of family member, or voluntary work hours for the keeping or abandoning their ideals.

3. Do I have the courage to reveal the corruptions the medical doctor’s society as Dr. Cronin did?

Among the 50 respondents, 15 students (30.0%) answered they would reveal the corruptions while 32 (64.0%) would not. The remaining three (6.0%) answered they cannot make up their mind (Table 1).
There was no significant difference in age groups, gender, number of family member, or voluntary work hours for revealing the corruptions of the medical doctor’s society.

Discussion

Reading literature is about the discipline of understanding from which spring awareness and autonomy [4].
Several special study modules (SSM) in ‘literature and medicine’ have been performed previously [5,6,7]. In a SSM of Glasgow, variety of books, plays, and poems were used with medical as well as non-medical themes. Cronin’s The Citadel was one of the 16 reading lists [5]. A 4-week course for the medical students of Newcastle, UK, the themes included empathy, death and dying, disability, madness and creativity, addiction, domestic violence, ethical dilemmas, doctor-patient communication, doctors’ emotions and end of life decisions [6].
SSM subject development in literature and medicine is challenging for students and tutors. In a SSM from Cardiff, Cronin’s The Citadel had been an example of seminar subjects: an one-day seminar, involving a visit to a closed coal mine located in South Wales, was intended to place in context references to The Citadel by Cronin, which is set in a South Wales mining community [7].
In literatures, doctor as metaphor was a difficult issue. In popular romance, the doctor may be heroic, handsome, and compassionate at a more serious level, however, doctors are rarely positive figures [8]. We have chosen The Citadel among popular books because it deals with the idea that money can and will corrupt an idealistic physician and shows the positive as well as negative figure of the medical doctor.
In the study, two-thirds of students (66.7%) wanted spiritual compensation to be the main reward for a medical doctor, while only one-third (33.3%) valued material reward (Table 1). It is very encouraging that young medical students value spiritual rewards so much higher than material reward in the current capitalistic era.
If they were in the same situation as Dr. Manson, three-fifths (60.0%) answered they would keep their ideals (idealist), while two-fifths (40.0%) would abandon their ideals in exchange for prestige and wealth (realists). The larger number of idealists represents the innocence of youth as portrayed in The Citadel. This seems to show that at this age the profession of medical doctor has an inherent worth not corrupted by commercialism.
It is interesting that less than one-third (30.0%) answered they would reveal the corruptions of the medical doctor’s society, while about two-thirds (64.0%) would not. It might be a mature appearance to seek a moderate way than exposure or accusation. It is also thought the students were worried to be treated as an outcast if they revealed the dark side of the medical field.
We attempted to analyse what medical students think ought to be their main reward in becoming a doctor through reviewing the popular and influential medical humanities book, The Citadel.
Most of the student did not read The Citadel before. Only a few students (five students) have read it, however, none of them remembered the storyline.
This study’s limitation is that, as the present study is not a kind of pretest and posttest design, the impact of this teaching mode on students’ beliefs or attitudes cannot be seen. Another limitation is that this study lacks the comparison between the ‘hobby’ of the students and results of the questionnaires.
In conclusion, it is encouraging that young medical students have a preference to a spiritual reward rather than a material reward in the current era of economic capitalism. The larger number of idealists represents the innocence of youth as in portrayed in The Citadel. Although it is uncertain whether reading and discussing the book has any influence on the students, we do believe the medical students may have chances to find their innocence of youth as portrayed in The Citadel during the process of writing book reports.

Acknowledgments

None.

Notes

Funding
This study was supported by a grant from Inha University (INHA-Research Grant).
Conflicts of interest
None.

Table 1.
Analysis of Book Reports on The Citadel
Category of analysis Response items No. (%)
Reward for the medical doctor Spiritual compensation Honor 22 (35)
Approval 7 (11)
Satisfaction 6 (10)
Respect 4 (6)
Happiness 3 (5)

Subtotal 42 (67)

Material reward Wealth 17 (27)
Prestige 4 (6)

Subtotal 21 (33)

Sum 63 (100)

Keep ideals or abandon ideals for prestige and wealth Keep 36 (60)
Abandon Reality 13 (22)
Wealth 6 (10)
Prestige 5 (8)

Subtotal 24 (40)

Sum 60 (100)

Reveal the corruptions of the medical doctor Yes 15 (30)
No 32 (64)
Cannot make up own mind 3 (6)

Sum 50 (100)

References

1. Cabot RC. Training and rewards of the physician. New York, USA: J.B. Lippincott; 1918.

2. Kernahan PJ. Was there ever a "golden age" of medicine? Minn Med 2012; 95: 41-45.

3. Cronin AJ. The citadel. Boston, USA: Little, Brown; 1937.

4. Skelton JR, MacLeod JA, Thomas CP. Teaching literature and medicine. J Med Ethics 1999; 25: 278-279.
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5. Calman KC, Downie RS, Duthie M, Sweeney B. Literature and medicine: a short course for medical students. Med Educ 1988; 22: 265-269.
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6. Lancaster T, Hart R, Gardner S. Literature and medicine: evaluating a special study module using the nominal group technique. Med Educ 2002; 36: 1071-1076.
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7. Jacobson L, Grant A, Hood K, Lewis W, Robling M, Prout H, Cunningham AM. A literature and medicine special study module run by academics in general practice: two evaluations and the lessons learnt. Med Humanit 2004; 30: 98-100.
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8. Skelton JR, Thomas CP, Macleod JA. Teaching literature and medicine to medical students, part I: the beginning. Lancet 2000; 356: 1920-1922.
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