Doctors need to earn their cynicism

You have to earn your cynicism.  That’s my rule.  Young pre-med and medical students, even some residents don’t have the same right to cyncism as the rest of us who have labored in emergency departments for years, for decades.  The same goes for nurses fresh on the job from training, and ward secretaries who so recently were high school kids.

It always troubles me when these people start working in our emergency departments and within a week are making snarky, toxic remarks about how stupid the patients can be, how ridiculous their complaints, how pointless their questions and how annoying their phone calls.  I agree.  All of those things are true.  But they don’t get to say it yet.

I find it troubling, worrisome when they do this too much, even in the first couple of years.  And yes, I know that they’re working with the same people as I am.  I know that drug-seekers abound, that people lie, that all too many of our patients take no responsibility for their illness, actions or life choices.  It’s maddening.  The entitlement, the neglect, the addiction.  But we have to encourage our younger, or simply newer, colleagues and co-workers to take a breath and count to ten; ten seconds, minutes, months, or even years if necessary.

The reason I feel this way is that cynicism is a tool.  And like a chainsaw or hammer, it requires education.  It is sometimes misused, but it is ultimately the mouthy half-brother of skepticism.  And we all understand the value of skepticism.  It makes us raise our eyebrows before refilling the lorazepam, hydrocodone, clonazepam and hydromorphone that the neighbor stole or the dog tragically ate.  Skepticism, even cynicism, makes us look twice at the child’s fracture and wonder if it was abuse.  Cynicism and skepticism cause us to wonder if perhaps that industry sponsored study isn’t especially useful.

Cynicism gets a bad name, because in our modern era we associate it with judgment or intolerance.  And these days, “who am I to judge?” is the rallying cry of a dying civilization … certainly a crippled health care system.  Despite the warm, fuzzy, well-meaning mantra that everyone has their own truth, we don’t, we can’t, function that way.  Judgement, discernment, these things are critical to our work.  And cynicism goes hand-in-hand with them.

As such, the tool cynicism must be honed.  It must be wielded by an experienced worker, who understands is uses and its dangers.  Cynicism is dangerous unless one has a large enough denominator by which to divide each numerator.  Students and new workers in emergency care have to learn that sick people may be crazy, but crazy people also get sick.  They have to understand that even the worst drug seeker may have a ruptured aneurysm and even the most venerable community leader may abuse her spouse at home. Cynicism is, in a way, necessary to an honest, open-minded view of the world.  It is the rifle scope that allows us to know what to tune out, and what we must see clearly.  Without it, everything is equally valid, everyone is equally honest, every tale equally true, every person equally ill.  While that sort of reasoning might satisfy administrators and the keepers of patient satisfaction scores, it is impossible, and woefully dangerous.

In a sense, cynicism requires an apprenticeship of sorts.  We see it, don’t we?  Young doctors taken in hand by older doctors.  Young nurses by seasoned nurses.  And if not, they should.  We should have no compunction about stopping someone and reminding them, “yes, he does seem crazy and whiny.  But make sure he doesn’t actually have an MI.”  Those of us long in the tooth, grey in the beard, have a valuable resource.  We have our vast, shared archive of experience.  We have all seen the 18-year-old MI.  We have all seen the innocent looking woman with the hidden knife.  The professor with the cocaine habit.  The sweet grandmother who drinks whisky like Gatorade.  We know, too, the pain of misses. The tragic outcomes born of cavalier dismissal of complaints, and the equally tragic consequences of believing everyone is telling the truth.  These are stories we have to share as we train our apprentices, as we slowly, carefully put cynicism in their own hands for the right uses.  But never, never at first.

Further, we do medicine, and its future practitioners, a disservice when we too easily welcome them into our cynicism as college students, or high school shadowers.  We have to temper our opinions and hold our tongues; or if we do not, we must qualify everything by saying, “it’s hard to tell sometimes. People aren’t always what they seem, for good or bad.  Be cautious.”

But it’s important for another reason. Cynicism is necessary for love and compassion.  If we simply, for convenience, believe everything we are told, by everyone; if we give equal gravity to every story and every complaint, then we really do not love well.  Cynicism, for a parent, is essential to raising children wisely and guiding them in truth.  And for the physician, for the nurse, it helps us to see past the surface to the real problem, the real issue.  It isn’t the fall, it’s the abuse.  It isn’t the chest pain, it’s the suicidal depression  It isn’t the anxiety, it’s the pulmonary embolus.  It isn’t the back pain, it’s the pending court date.

Finally, while it sometimes seems that we develop (I believe) more compassion over time, what may happen is simply that we learn how to save it, to ration it, for the best and most necessary times, the most deserving individuals.  I cannot muster compassion as easily for the person whose actions, over years of repetitive abuse of his or her body, result in sickness and trouble.  I have difficulty being compassionate for the malingerer who only wants another work excuse and another shot at disability.  I have to reserve it for those whose problems are life changing, life shattering or simply painful and scary.  For the sick child, the worried mom, the dying husband or wife.  If I try to shower compassion, free of cynicism, on everyone I see, then it will be a mere sprinkling, not an immersion.  My well will run dry and my patients may suffer.

So dear friends, students, co-workers, don’t shun cynicism.  It is absolutely essential.  But before you embrace it, wait and look and see.  Fill your archives with stories. And fill your hearts with love.

Then, you can tell me about those crazy, drug-seeking, lazy, good-for-nothing patients who drive you crazy.  Because like me, by then you’ll even care about them.  Just a little more wisely.  And that sort of love, without any delusion about the one loved, is a goal worth achieving.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test. This article originally appeared in Emergency Medicine News.

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  • DoubtfulGuest

    Nice post, Dr. Leap. First of all, thank you for not using clichéd, gender-stereotyped examples of abuse. Thank you for acknowledging so eloquently that doctors can make mistakes with “what they see” in either direction. The patient’s character and actual medical situation can be alternately much better or much worse than you all expect. I’ve been harmed by doctors who didn’t control their cynicism and they were just basically lashing out, evidence be damned. So this post is very relevant for me and I really appreciate it.

  • John C. Key MD

    Cynicism is very easily earned. Any school with strong clinical programs should be able to certify cynicism by the end of the third year.

    • DoubtfulGuest

      Cynicism. The gift that keeps on giving.

  • http://www.drsocial.org brettmd

    Oh goodness, please do not be cynical. Anecdotally, it creates a terrible work environment. Many of the United States laws are based on the principle that people are innocent until proven guilty. For criminal law, this includes innocent until proven guilty beyond a reasonable doubt. In civil trials the burden of proof is less, but again, innocent until proven guilty. However, medical boards and the related regulations encourage a “guilty until proven innocent,” cynical mentality. Skepticism and judicious medical decision-making are gifts that may be passed on. Cynicism is the gift of abuse that keeps on harming.

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