I'm doing a combined internal medicine and pediatrics residency and I'm in my third year now, but I took almost a year off last year to do an International Health Fellowship with the American Medical Student Association. I did a half-year of internal medicine as an intern and then to all appearances vanished for a year and a half. Now I've returned, and my fellow diffident interns are suddenly senior residents. The change is remarkable.

I remember my first morning report after I came back from Nigeria; Jeff, who had been an intern with me on the general medicine rotation, was there, and I was glad to see him. He had kept himself dissociated from the medicine game as an intern; he asked questions when he didn't know what to do, he never flaunted what he did know, and he abstained from passing judgment on others. His lack of pretense had made him a pleasure to work with. That day in morning report, he seemed transformed. Now he was the senior resident: citing statistics, firing off questions, quoting journal articles, summarily dismissing others' hypotheses—and doing this more out of arrogance than confidence. It was abundantly clear that the other residents at morning report were impressed by him. They would not have been impressed by the old Jeff, my friend, the quiet intern, but I was, and I found this new Jeff depressing. I found myself thinking, if this is what a good residency does for you, let me drop out now.

It's two in the morning. "What a flog," I say to my intern as I walk into the conference room from a patient's room—and I mean it. This is patient number 10; he has a problem list two pages long with almost every organ system affected, and at this hour of night I'm expected to make him better. I'm going through his history with a fine-toothed comb so I can answer the sometimes inane questions thrown out at morning report. I feel abused. I am sick of answering pages, of writing endless admission notes, of feeling constantly behind, of worrying that I'm missing something important, of ordering unnecessary tests for unlikely diagnoses. But where is the patient in all of this? Is he flogging me? If he is very demanding, he may be part of the problem. But more often than not, the patient, his confidence in me, and his strength despite his illness are the things that keep me going.

In our residency the buzzword is "strong," as opposed to "weak". It's macho language, full of sound and fury, signifying nothing. Anything you disagree with or feel too lazy to deal with is "weak"; anything that saves you time is "strong". We live by these codes, and early on we learn to hide what we don't know, to overstate what we do know, and above all else to be categorical with our answers. There is also a pervasive idea that the only way residents can show how good they are—how "strong"—is to point out mismanagement by the other residents and by the hospitals that have dealt with their patients. People get lost in this maelstrom of rhetoric and pontification; their role in the medical system becomes their definition: a "fascinating" case, a "weak" resident, a "strong" intern.

It's four in the morning. I'm passing by the general medicine team. They're admitting a patient with peritonitis. "It's another dialysis troll," the intern says with disgust. That's how they are known—"trolls"—the patients needing long-term peritoneal dialysis who can't seem to stay out of the hospital. The complications of their original disease give them a characteristic appearance: They are small, with short arms and legs, bloated abdomens, and mildly puffy faces, and they are often demanding and rude when they come in. Hence the term "troll"—an unjust, demeaning term. Would we ever say it in front of a patient? Do we really mean it when we say it? I don't think so. It's an expression of our frustration at our lack of a cure, our perception of ingratitude, our exhaustion at four in the morning. And if the patient signs out against medical advice, just when we were getting him or her healthy again, the slur seems justified. How glibly the word rolls off the tongue, not just for noncompliant patients receiving dialysis, but for anyone troublesome. They're "trolls". The third-year students quickly pick up the word. They use it to show that they know our medical terminology. And thus they too become corrupted.

I think of the two interns on my service last month. They were exceptional; they spent hours with their patients and the patients' families, listening to them, caring about them. They knew their limitations, they knew their strengths, and they were honest about both. I found myself praying that they would stay that way, worrying that they would not. It's hard to go through a residency and remain above arrogance and cynicism. The attitudes are pervasive and encouraged. Without brashness and bravado, one's voice is sometimes lost in the chatter. How sad, and how unnecessary. Seeing how patients can suffer because of the complexities of modern medicine, seeing how residents can flourish and thrive in an atmosphere of conceit and pride, we have to ask: Who's being flogged? And who are the trolls?