In medicine, is there a place for learning from those we serve?

Inhalation. Exhalation. Perspiration. Equivocation. Self-Abnegation. Devastation. Urination.

The list of things I’ve endured in the name of getting to medical school could go on, and I doubt it’s any different from my classmates’. But we’re here, finally, freshly white-coated and already racing just to stay on track.

The White Coat Ceremony was a timely, though sometimes tearful reminder of what we did to get here, why we did it, and what we’re in for as medical students and physicians. It’s worth noting, though, that it is a young part of medicine’s long history—the first ever took place in 1993. The goal was—and has been—to inject a bolus of humanism into students right as they stumble into the start of their medical training.

Most of us students have read articles and heard admonitions about how medical students’ empathy declines precipitously as they enter their third year and start seeing patients full-time. In fact, when I worked at Columbia’s Program in Narrative Medicine and founded a Working Group on Patient-Centered Medicine, empathy erosion in medical school came up about as often as what was for lunch that day—which is to say, pretty often. I even wrote my undergraduate thesis on physician-patient communication, in hopes that it would make me (and others) a more humanistic and effective clinician.

Despite all that, after reading The Soul of a Doctor (a collection of medical student essays), I feel energized but utterly unprepared to handle the constant trauma of two years on the wards while maintaining the attentiveness and empathy that each patient deserves. It’s easy to play the armchair third-year, thinking through what the students should’ve done from the comfort of a La-Z-Boy. But I worry that every student writing about their regrets from a less-than-ideal patient interaction had the same idealistic “preparation” (scare quotes intentional) that I did. I worry that when the excrement hits the fan, I too will miss an important cue, disregard a difficult patient, or cower back into my insecurities when the job demands nothing less than my whole self.

How do we inoculate ourselves against desensitization, against cynicism, and against the wretched tendency of hospital staff to refer to patients by their conditions?

Though could it be any other way? We heard speech after speech about how it’s our duty to carry ourselves professionally and ethically, and above all to “be humanistic.” But what does that actually mean? Does the act of talking about humanistic medicine make our medicine humanistic? Or is it something like the Supreme Court’s definition of pornography—“I know it when I see it”? If it’s the latter, how do we as students learn it? How do we inoculate ourselves against desensitization, against cynicism, and against the wretched tendency of hospital staff to refer to patients by their conditions?

I don’t claim to have the answer. But I have an observation: as a fledgling member of the profession, I’ve noticed medicine’s solipsism—its tendency to refer to itself as the beginning and end of all it touches. I’ve noticed language like, as physicians, it’s our duty to… [fill in the blank], the assumption being, we know what the problem is and we alone can solve it. Part of me loves “professionalism” lectures, because they remind me that I am answering a calling different in kind from pretty much anything out there—one showered with respect, privilege, and independence. But I wonder if that is the root of the problem: that in the course of medical training, despite becoming more intimate with the human body than ever before, we learn that our toil and training makes us different from our fellow humans.

In the White Coat Ceremony, just as we begin to part ways with the rest of humanity, we’re exhorted to be humanistic. And yet, every speech we heard, every book and essay we read, came not from a patient but from a medical professional. Indeed, we are entering the medical profession. But in such a noble profession, one that emphasizes lifelong learning and service to others, is there a place for learning from those whom we serve? Before long I’ll be able to see an entire world inside a patient’s eyes–but I wonder when I’ll learn how the world looks from behind their eyes.

Karan Chhabra is a medical student who blogs at Project Millenial. He can be reached on Twitter @KRChhabra.

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  • Marian63

    Very interesting and informative post. While I was reading it, I was reminded of my friends whose career involves managing animal shelters and animal-care programs. The best of them have both detachment and empathy, a very difficult and paradoxical balance. The emotional toll is enormous – not only on managers but also on volunteers. Every day they must see and even preside over the euthanization of animals. And too many people don’t see animals as deserving of attention and care and compassion, so often there is very little outside emotional support for the work they are doing. I could not do that work. I am a layperson, not a medical student or an MD, but I would hope physicians could look at people in animal-welfare programs and take comfort from the fact that their own work is seen as extremely valuable and that no matter how difficult a patient is, understanding and perhaps saving him or her is a worthwhile task. Probably all this is naive, but I wanted to share my thoughts.

  • kadiera

    I would hope, as the parent of 2 complicated children, that doctors would learn from patients (and their care givers) . While I may not have a medical degree, I am more familiar than anyone with my children’s specific cases and the way their issues present. I know as much as any resident is likely to know about their conditions (and frequently more than the residents rounding on my kids) . Compassion and a little humility from doctors goes a long way in their relationships with parents.

  • Bruce Ramshaw

    Great insight, Karan. Our system structures for for healthcare (hospital hierarchy and silos, and physician individual practice model) are no longer adequate to deal with the increasing complexity in healthcare and in our world in general. Those system structures are causing harm to patents (medical error, dehumanization, etc.) and to physicians and front-line staff (depression, burnout, disengagement, etc.). It is the system structures we work in that produce the behaviors exhibited, including the decline in empathy.
    I believe that we will need a structural change in how we care for patients to achieve significant improvement of our current situation. I believe the most important stakeholder group to learn from is the patient and family. When we evolve to team-based care designed with and for definable groups of patients (by disease or problem, for example), and we apply principles of complex adaptive systems science (continuous learning and clinical quality improvement), I think we will see the improved value (for all stakeholders who add value to the patient) that everyone is striving for.

  • Stephanie Frederick, RN, M.Ed.

    As a well-seasoned RN, I’m aware of the 24/7 connection nurses make with their patients. It’s indeed a “systems” problem when understaffing, increased demands, and decreased resources are the hurdles we encounter. Physicians will become increasingly aware of these problems as they leave their private practices and become facility employees. The patient care damage won’t be addressed until the public steps forward and demands change in our “health care” industry. There’s a perfect storm brewing…

  • carolynthomas

    Karan, I first assumed your title was a rhetorical question, one so obvious that no answer would be expected for those intending to practice medicine in the 21st century.

    But your summary “I wonder when I’ll learn how the world looks from behind their eyes” tells me that you are likely fortunate enough to have little if any personal experience so far being the one lying there in bed wearing the drafty hospital gown, feeling sick, scared and helpless. Not that I would wish illness or hospital admission on any person, but the more I read from docs who have actually become patients themselves – along with their inevitable “Eureka!” reactions – the more I think we should not let med students loose on sick people unless they have been forced to spend at least 24 straight hours trapped in the same uncomfortable, dehumanizing, noisy, humiliating, frightening and undignified setting that their patients occupy. More on this at “When Doctors Become Patients”:

    Welcome to our world! Until you have this experience, you and your peers simply will have no idea how your “toil and training” may indeed be serving to “make you different from your fellow humans” – a sad reality for any physician.

  • The Gold Foundation

    The White Coat Ceremony was created by the Arnold P. Gold Foundation as a pledge and reminder that the qualities of compassion, empathy, altruism, service, respect, and excellence are integral to becoming the type humanistic physician most medical students transpire to be. It is a moving moment and many physicians remember it as one of great importance. However, it is one moment at the beginning of a long and grueling period of education and training. The fact that you understand, as an incoming student, that there is a difference between your perception of a patient’s experience the patient’s perception of their experience already puts you ahead of the game. Most patients will be happy to tell you “how the world looks from behind their eyes” if you take the time to ask. Developing the habit of asking each patient with a genuine interest in knowing the answer, even when time is short and you are pressured, will help you to be the humanistic physician you pledged to be at the White Coat Ceremony.

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