Julianne A. Mann
Cell 2 Soul. 2007 Spring; 3(1):a7
A hot topic in the popular press these days is the concept of empathy: specifically, can it be taught to medical students? Equally critical in my view is another question: can a medical school education actually dampen that empathy inherent in most young doctors-to-be? In the first two years of medical training, the "classroom years," we are taught how to listen well and engage emotionally with patients. Our professors read us passages from Osler's writings and urge us to see the person behind every illness. They reassure us that it is permissible to cry with our patients when breaking bad news. All of this feels right and good.
And then somehow, despite the attention devoted to teaching us "good medicine," bits of cynicism and insensitivity begin to creep into the experience of many students as they progress through clinical training. Early in my third year a resident taught me the meaning of the terms "train wreck" and "frequent flyer." When a nurse overheard me making phone calls to set up a social work consult for a patient with a 25-year history of substance abuse, she told me not to bother, saying the patient was already "too far gone." Presenting a patient on morning surgical rounds, I was instructed to omit the patient's profession and social history unless it was crucial to the diagnosis. Stating that the patient was a 54-year-old retired librarian who had recently moved to the area from Philadelphia was irrelevant to a diagnosis of appendicitis, my attending explained. "Skip the 'extras' and streamline with your presentations," he advised. What ever happened to painting a picture of the person behind the illness?, I wondered.
In a busy outpatient clinic at a Boston hospital where I worked, patients were given 7-minute appointment slots. As we bustled in and out of exam rooms, the attending physician began sharing bits of advice on how to keep up this kind of pace, how to maintain efficiency. "Do the physical exam first," he said. "That way you can write your note while the patient is talking. And if the patient is talking too much, no need to interrupt…just cross your arms, lean back and look bored. This will make them think that they have been talking far too long and will put a stop their prattling." He shared this advice with me excitedly, proudly, as if his wisdom would spare me some of the trouble that he had endured while listening to long-winded patients complain about failing vision or dry eyes.
Don't misunderstand me-I have had some wonderful mentors during my clinical years, many of whom were inspiring teachers. These residents and attending physicians supported me wholeheartedly in my quest to become a compassionate, humanistic doctor. They helped me stay inspired, fresh and hopeful. But in my day-to-day ramblings at the hospital, sometimes it's a struggle to hear their voices amid the low steady hum of cynicism. Many physicians forget that displays of negativity or frustration, even if subtle, can easily color the experience of students and residents. I realize that things can't be sunny all the time — we all regularly face difficult patients and administrative headaches. But as students, we need to be taught how to field these challenges with patience and compassion. What better way to do this than by watching our mentors?
Another lesson that students learn early on in their clinical years is their position on the medical totem pole. On a rotation at a west coast hospital, I was told by a resident that at Departmental lunches medical students should eat only after the house staff had taken their food. Sitting at the edge of the room, I watched the hungry residents pile their plates high with sandwiches and fruit salad. Later, as I surveyed the leftovers, I marveled at the absurdity of this food chain.
At a number of high-profile hospitals, attending physicians and residents sometimes don't introduce me when I accompany them to see a patient. It's an awkward scenario: the patient greets the physician, then glances at me, waiting for some explanation of who I am and why I am there. When the senior physician launches into history-taking without introducing me, I'm left standing awkwardly in the corner of the room, feeling like an uninvited guest.
At Dartmouth-Hitchcock, a medical center that prides itself on the practice of patient-centered, humane medicine, I have been taught to introduce myself to the patient and his family prior to surgery. Not only is this the polite thing to do, but it spares the patient from the anxiety of seeing an unknown face in the OR. Once, while on rotation at another well-known East Coast institution, I introduced myself to a patient and her husband as they waited in the pre-operative suite. I told them I would be observing the surgery, a minor procedure that would only take about 30 minutes. The patient smiled warmly and told me that was fine with her, that she was glad to contribute to my learning. As I walked away from the bed, the attending physician stopped me in the middle of the hall. "I know you probably meant to be friendly," he said, "but I'd prefer that the patient not know you're in the room. It just makes them more nervous to know there's a student around. Honestly, it's better if you're sight unseen until they're under anesthesia."
When team members don't listen to medical students presenting at morning rounds, it sends the same message. As we report the "24-hour events" and lab results, one resident makes a grocery list, while an intern checks his palm pilot for new emails. When we finish, we're asked for data that we just gave in our presentation, driving home the reality that no one was really paying attention. Our attendings and residents teach us to be present, to listen carefully to what patients say. Why shouldn't we be given the same degree of respect?
As physicians move up the medical ladder, they need to remember that they are powerful role models. Their behavior toward patients and colleagues and their attitude toward the medical profession color the experience of those around them. If they show subtle cynicism, negativity and impatience, it will impact even the most well-intentioned medical student. They can just as easily create an environment of enthusiasm, compassion and kindness. One of my favorite attendings used to share a quotation by a wise physician or read a compelling passage before morning rounds with the team. The exercise took less than a minute, but it set the tone for the entire day. It reminded everyone why we were there, and affirmed what a great privilege it is to be both a physician and a healer. One day I hope to provide such inspiration and enthusiasm to my students and colleagues.