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INCIDENT REPORT Toward Putting Down The Put-down The response below was written by Gordon Harper, director of Patient-Doctor III and an HMS associate professor of psychiatry at the Massachusetts Mental Health Center. Incident as reported by a student: One night in the emergency room, the residents began joking about a homosexual patient, laughing about "this faggot." Seeing the look on my face, the chief resident asked whether I was gay. I replied that I was not but that I had plenty of friends who were. The group laughed. Then they changed the subject, laughing at the morbid obesity of a patient they had seen that day. "Oh, sorry," the chief resident chuckled while facing me. "Do you also have friends who are fat?" Response: When medical students speak about negative experiences during clerkships, they often mention disparaging remarks made about patients. While such behavior is offensive in any context, it is especially troubling to future physicians because it violates their hope that their teachers' behavior will reflect the Hippocratic principles of medicine. Such principles notwithstanding, put-downs of the vulnerable have long been a part of medical culture. Students have always picked up this "informal curriculum" in corridors and lunchrooms. But in recent decades, several developments have made it more likely that practice will reflect the best of our traditions. Previously disempowered groups--ethnic and sexual minorities, the disabled, even medical students--have found their voice and demanded respect. Medical professionalism has found its place in the formal curriculum. And a new kind of professional authenticity has broken with the convention of "double-entry" patient-doctor communication, a perverse etiquette that had us thinking we could respect patients at the bedside while speaking disrespectfully of them in private. We are also moving toward a more inclusive professional identity. Medical solidarity achieved through putting down the vulnerable reflects the myth that doctors must be invulnerable--that patients are different from the healthy "us." As we confront put-downs of those we serve, we are growing together beyond this old myth and forging a healthier sense of ourselves.