I never understood the loss of empathy during medical training. Until now.

I never understood the loss of empathy during medical training. Until now.

It was 4:30 a.m., and I was on the side of the road, drenched in sweat and tears. I had finally slowed my breathing to normal. I was going to be late for rounds. No time to obsess over possible questions. No time to memorize lab values, or practice regurgitating them.

I thought of home. My family and friend, who I hadn’t seen in months. I cringed when I estimated how long it had been since I called them. And the place itself. The dry, clean heat of the desert. The pump jacks that dotted the landscape. The men with their muddy work boots and weathered skin. The brave, unconventional beauty, the humility of the region. And my heart ached to be there, to go back to a time where I was bright and hopeful. I think that’s where most of my sadness came from. Grieving the loss of her, the girl who wanted to do something that mattered.

I attended my dream school. I remember the day that I received my acceptance letter as one of the happiest in my life. I was going to learn from some of the smartest doctors in the world. I felt blessed. As a young man, my grandfather had crossed the border to pick cotton. His third grade education and shaky English would keep him working manual labor jobs for his entire life. My father was the first to graduate from high school. He, like most men back home, worked in the oilfields. And I was going to medical school. My family couldn’t help me fill out the applications or pay for the MCAT (I worked at a coffee shop to cover that). But they were my biggest fans, my cheerleading squad.

My decision to choose medicine was emotionally motivated. My mother became very sick during my junior year. She spent months in hospitals, on respirators and feeding tubes. I watched my mom suffering, and I hated that I didn’t understand what was going on, that I couldn’t help. Soon after she came home, I announced I was going to medical school. I had never been so sure.

We experienced intense stress and pressure to perform, to produce results. Early on, I stopped attending lectures, and watched from home. I could speed up the recording and learn twice as fast, I reasoned. Alone in the small apartment that my loans afforded me once I paid the hefty tuition bill, I worked diligently to produce what were considered mediocre grades at my institution. It is difficult to explain the isolation, the emptiness of this time. Those are two years I’ll never get back. Two years of youth and good health spent in an apartment.

I would call my friends and family often in the beginning, sobbing and anxious. But how could they understand? To them, to the outside, a doctor’s life seemed very glamorous indeed. After a while, I stopped calling.

The only patient contact I received were not real patients. They were actors. Once or twice a semester, we would conduct earnest interviews with these pretend patients. We would be timed, filmed, and graded. Even our interactions with other human beings were carefully scripted and judged. If my university believed in one thing, it was that there was no human enterprise on Earth that could not be held to a rubric. They had yet to fail in their quest to quantify, to measure all of the qualities of an ideal doctor.

Then the grand finale: step 1, or as I like to call it: “The Most Important Test On The Planet: If You Screw Up You Will Never Get The Residency That You Have Dreamed About Since You Were Three Years Old.” Weeks of cramming material into my head. I drank coffee. I studied. Period. I was motivated by the promise of the clinical years. I was finally going to be able to interact with humans again. I prayed that the motivation, the drive I had lost somewhere along the way would return.

My happiest times in school were early in the morning, before the residents and the attendings were around to expose the holes in my knowledge, or reprimand me for forgetting to test cranial nerve IX, or scold me for my presentation being too long (or too short, depending on the person.) It was listening to my patients as they told me about their children. Their patience as I clumsily stumbled through the interview. The way their face relaxed as I told them that I would bring up their concerns to the doctor. Holding their hands and telling them it was going to be alright. Laughing, connecting, loving. Ironically, the shortest parts of my day. No time for that sort of thing with notes to write, tests to study for, articles to look up.

I attempted to explain the situation to the school psychologists. I tried to convey the sense of loss, the unmet expectations, the dying of a dream. I was told I was experiencing severe depression and anxiety, feelings that were internally generated. No possible flaw in the system, they rationalized. After all, there were rubrics. I was assured it would take months to treat me. Best to get on with it, numb up in time for the next rotation. Instead, I took a leave of absence.

I have been silent for too long. I have asked, “What’s wrong with me?” when I should have been asking, “What’s wrong with this?” I am compassionate and hardworking, yet I have been daily made to feel inadequate. I have been isolated from the people and the pursuits I love. I have given up everything, paid thousands of dollars, thousands of hours. I have repeated to myself over and over, “there is only medical school.” I almost believed it.

I never understood the trend of loss of empathy during medical training. Until now. See, when you’re in so much pain that if you thought of your life past this moment, this singular point in time, you would implode, pain seems as natural as breathing. Pain is part of life. Pain is nothing. You can’t stop to nurse your own wounds, you can’t talk about how much you hurt. So how could you possibly have enough room in your broken heart to take on someone else’s pain? So you don’t. You cover your bases and survive. You become that machine that you swore you’d never become. Because it hurts too much to feel, and it’s so much easier to float than swim.

I fantasize daily about leaving medicine for the endless sky back home. I miss the person that I was so very much. But I’m still here. And I hold onto my faded dreams in my little hands.

Why?

I remember that hospital room that smelled of isopropyl alcohol and sickness. I remember changing the sheets my mom soiled because the nursing staff was short in our small hospital. I remember the cold, detached doctors that came for ten minutes once a day. I remember how they spoke in riddles, how they seemed so far away. I remember.

I promise I won’t forget. I’ll never forget.

The author is an anonymous medical student.

Image credit: Shutterstock.com

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  • http://www.idealmedicalcare.org PamelaWibleMD

    “I tried to convey the sense of loss, the unmet expectations, the dying of a dream. I was told I was experiencing severe depression and anxiety, feelings that were internally generated. No possible flaw in the system, they rationalized.”

    The fatal flaw of reductionist medicine is that it kills the spirit. In doctors. In patients. There is no meaning in a heartless and soulless life. The first step to healing is recognizing the problem. Thank you for being so courageous to speak out.

    • RenegadeRN

      Yes, it kills the spirit in nurses as well. I had to get out of the hospital to hang on to mine.

      • http://www.idealmedicalcare.org PamelaWibleMD

        They say, “Nurses eat their young.”

        Why?

        Why is that necessary?

        • Ladyimacbeth

          I’ve only ever noticed this when I worked on the floor. I think it has to do with the fact that the floors are continually understaffed, and everyone is stressed out. Nurses don’t have enough time to get their own work done much less the time it takes to mentor someone new. We didn’t even have time to pee.

          I haven’t noticed older nurses dumping on the new nurses in other areas I’ve worked, and I think it’s because there is less stress in those areas and people feel more human. It’s amazing what it does to your mood when your job allows you enough time to pee and eat lunch.

          • RenegadeRN

            Couldn’t agree more!

          • http://www.idealmedicalcare.org PamelaWibleMD

            I know. Right.

        • RenegadeRN

          I’m not really sure, truthfully. I experienced it to an extreme degree in my first ICU job.
          I caught a nurse in the break room crying one day and later found out she was crying for ME! I remember driving home every morning for at least a month , crying from the cramps in my neck and shoulders from the stress of the previous 12-13 hr shift and being told “what you don’t know will kill someone’s baby!” Harsh huh?

          I have never treated a new (or new to the unit) nurse like that. I am, by nature, a teacher and try to help them come up to speed.
          That’s not to say I haven’t become exasperated with a LVN once who preferred to hang out in a med room once and read magazines rather than work! Overall, teaching trumps anger and snark every time.

      • Ladyimacbeth

        There is no amount of money you could pay me to go back to the floor. I took a pay cut to get out of there.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Spent all evening counseling my cousin who is miserable in a toxic nursing job. She wants to work at Trader Joes.

          • Ladyimacbeth

            Tell her there are other jobs she can do as a nurse where she will actually have time to pee and eat lunch. I became a research nurse and was a lot happier, despite the pay cut. I still got to have patient care (which I loved) without all the stress of working the floor. There were certainly stresses in that job, as well, but nothing like working on the floor.

            With my current job I work 8-4:30 with a 30 min lunch (that I actually get to take), breaks to pee, and I’m able to telecommute part of the time.
            She doesn’t have to stay in a toxic environment. There are lots of opportunities for nurses that don’t involve sacrificing your sanity. If I knew then what I know now, I would have left the floor a lot sooner.

            My hat is off to any nurse who works in those high stress environments. It makes me angry that hospitals don’t do a better job making sure there are enough nurses hired to take care of patients. They’re killing the ones who are there.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Trying to get her to break free and do home care on her own terms without an agency.

          • Patient Kit

            It may be all an act, but the employees at my TJ’s in Brooklyn seem pretty happy. Not saying that a nurse should work in TJ’s, just that it’s possible for employers to treat their employees well.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yep!

          • RenegadeRN

            Boy do I ever understand her frustrations. When I quit the hospital I declared I would “flip burgers” before I went back….and I MEANT it! Ha ha

          • http://www.idealmedicalcare.org PamelaWibleMD

            And where are you now?

          • RenegadeRN

            Kept my nursing license and about to take my national boards in nutrition as a CCN. I think it will nicely merge my medical knowledge with a lifelong interest in nutrition.
            I’m thrilled to have an established practice to go to.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Yes. My mom (a retired psychiatrist) just wrote in response to this essay on my Facebook: Judith Wible This narrative describes what I experienced in my medical training.

  • azmd

    I also went to medical school in the 80′s and I believe that the point that is being made here is that medical training has changed tremendously and in certain ways can be psychologically harmful to students. That harm can cause them to lose empathy, a known effect of medical training and one which I think is hard to say prepares a student well to be a “wiser, more experienced healer.”

    I teach residents and students and am routinely somewhat horrified by the rigorous tasks they face which far outweigh anything I had to do at an Ivy League medical school in the ’80′s.

    • http://www.idealmedicalcare.org PamelaWibleMD

      The workload and suffering is already so much to bear. Then the hazing, bullying, and outright abuse can push people over the edge—literally—we lost 2 more docs to suicide when they jumped from hospitals in NYC to their deaths. More here: http://www.idealmedicalcare.org/blog/how-to-graduate-medical-school-without-killing-yourself/

      • Patient Kit

        I saw that recent tragic local news. One from NYU and the other from NY Presbyterian. They don’t mention that their docs are jumping off their roofs in their glossy, heart-tugging advertisements. 25 and 26 years old. As always, so sad. Keep up your good work on this very important issue, Dr Wible. :-(((

      • http://www.thepatientdoc.com The Patient Doc

        I live in NYC, and I clearly remember being on the top of my hospital roof, look down, wondering what would happen if I just jumped. That was multiple times during residency. Things are a bit different now. I still hate the way things are, but I don’t work at a hospital, so no big building to jump off. I think my attitude has changed too. I’ve accepted he way things are and that they are out of my control. I rely solely on my faith to get me through, and believe that things will get better. Whether I stay in medicine or not I can’t be sure, but I know things will get better somehow.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Wow. Do you think others in your residency felt the same way?

    • http://www.idealmedicalcare.org PamelaWibleMD

      azmd I’d love to connect regarding medical education reform. Check out the blog link below. I spoke at a local med school and got a standing ovation from the students. They are hungry for real human mentors. Where do you teach?

  • guest

    You never get that ability to feel empathy again. The brain can block emotion, but it has to block both positive and negative at the same time. It has no ability to selectivelly block negative. As long as medicine is a business it will be full of negative emotion as health care providers will be abused by the system. That is why I do not recommend med school to people who like to help other people. You are just a worker in a medical industrial complex. No wonder you feel bad. Once you graduate it will be like that movie Brazil or even bette, 1984.

    • Patient Kit

      I agree that if you numb out to stop feeling the negative stuff, you usually also stop feeling the good stuff too. The choice is to be in touch with and feel your emotions or numb out and squash them. I disagree though that once you lose the ability to feel empathy, you can never get it back. You may need help, but you can get it back.

      • http://www.idealmedicalcare.org PamelaWibleMD

        I think most doctors need therapy, a lot of therapy.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yep. Can be harsh for those who are so altruistic and noble in their intention to serve humanity.

  • Dave

    While I know stories like this are common, I must say that my experience was nothing like this and that I thoroughly enjoyed all of medical school and don’t feel like I lost any empathy at all. If anything, my sense of empathy only intensified. Sure, there were periods where I would say I felt burned out, but these were short-lived. Yes, there were emotionally draining times — rotations in the ICU come to mind — but there were also emotionally uplifting times. I developed lasting relationships with my attendings and residents that continue to this day. Sure, there were some duds in the bunch, but the overwhelming majority were great people, kind, and devoted to teaching.

    I wonder how much the feelings expressed in the article are a function of age. I was 10+ years older than the rest of my class so maybe that had something to do with it. The other non-traditional students didn’t seem to experience anything like this article describes either. I’d be curious to see a study looking at this.

    I wish I had an answer. My n=1 experience suggests there isn’t so much a systemic problem as there is a problem with how individual students cope with stress. Some of the people I saw without much empathy at the end didn’t really have much when they started either.

    • Anne-Marie

      Maybe some of this is generational? The experience of growing up is just different these days – fewer kids per family, more personal space, more structured activities, much greater access to technology, more multitasking and distraction, new avenues for bullying… (yup, I’m a boomer) I grew up in a large family where I was not a special snowflake. Maybe the current crop of medical students is being trained within a curriculum that isn’t well adapted to the social and psychological development of their generation.

      All of this is a huge generalization, of course.

      • http://www.idealmedicalcare.org PamelaWibleMD

        Yes I do think there is merit to this. But not sure I’ve seen any serious investigation into this.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Protective factors:
      1) Older age – You just have more real-life experience than the younger kids who feel their lives are on the line if they don’t achieve. Plus more wisdom.
      2) Having a family (spouse, kids) – built-in support and deterrent to making a fatal decision.
      3) Less sensitive people – some students are just not as empathic and sensitive to the pain and suffering in others. I do not mean that thee students are not empathic, but they do not have that “hyper-empathic” response to suffering in others.
      4) Humane med school and workplace – some docs just have a better experiences with less sadistic mentors and a better overall sleep and work schedule.
      5) Left-brained folks – As a creative right-brained person, I had to work twice as hard as those who were just built for the left-brained medical school experience. More studying. Less sleep. Feeling more isolated and “different” than the herd.
      6) Lack of underlying mental illness.

      Probably others.

      • Dave

        1,2,4, & 6 were definitely there for me. Even at my school there were some students who felt like the author of this piece. Im definitely right brained though – actually my first career was as an artist! Maybe that gave me a thicker skin and ability to take criticism without losing my confidence.

        In retrospect, I think I viewed much if the med school culture like a game and never took anything personally. I also made a choice to focus on the human side and really get to know my patients. When other students were heading for the doors to go study, I was sitting down with my patients and their families, not for a grade or anything, just because it brought me joy. I laughed and cried with these people, and whenever a patient passed i always sent a handwritten note to the family and attended the funeral if able/appropriate. Never told anyone about it, just did it quietly. I think that’s a big part of how I held on to my empathy. Students are some of the only people in the hospital with the time and freedom to do that sort of thing. It was definitely good for my soul, and I hope I helped do the same for my patients.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Wow! You must be an AMAZING doctor!! And artist! Whoa. Great combo.

    • Dan

      I have the exact same sentiment but am only a couple years older than my classmates. I feel that I have more empathy now in my 4th year than I did before the clinical years, and I’ve never felt myself lacking in that department. Some ups and downs but it’s definitely a privilege to do what we get to do. I worked a couple years before med school so realized that the majority of my peers were working dead-end jobs with little meaning. Maybe that helps keep things in perspective. I definitely worked hard during med school but I’ve made some amazing connections and learned a ton. I always studied with friends so that probably helped with the isolation as well.

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    Over 25 plus years ago, I started my healthcare career working in a medical school. I have seen some positive changes, but not enough. The lectures are still incredibly tedious — I think all people who teach in med schools need to undergo presentation skills training. Also, people in medical education, especially at the clinical level, need to learn effective methods of providing constructive criticism. On a daily basis in my work with practices & hospitals, I witness very poor communication skills. I also find that physicians feel that they have little impact with admin decisions. Many drs tell me they no longer offer suggestions since they feel no one cares what they have to say.

    • Suzi Q 38

      I think that joining a public speaking group like “Toastmaster’s International” would help.
      I have sat through some of their lectures. Some are so boring!
      Please tape the professors classes and show them where their strengths and weaknesses are.

  • logicaldoc

    This person is a “Medical Student” and already articulates how many of us 23 years after Residency feel.

    I truly worry and have “empathy” for you (whoever you are) because if you already feel this way, you will never make it or may end up doing something dreadful. Please seek help for your woes is my best suggestion.

  • querywoman

    This happens in all the helping profession. The main cause of death in police officers is suicide, not a suspect’s bullet. When I worked in public welfare, I got a little hardened.
    I always wonder how many doctors who, after all that intense training, leave medicine because they decide it is just not for them.
    The loans can be negotiated if you know you just can’t hack medicine.

  • http://www.idealmedicalcare.org PamelaWibleMD

    There’s a lot to be said for a humane work environment. :)

  • http://www.idealmedicalcare.org PamelaWibleMD

    From your research what methods would you suggest the medical schools employ?

  • http://www.idealmedicalcare.org PamelaWibleMD

    Ridiculous that we allow young doctors to be treated this way.

  • Sara Stein MD

    Am I the only one who wants this person to get to a doctor asap? To the author, well expressed, but the boot camp has a purpose. Your patient does not need you to cry with them, they need you to provide knowledge, organization, guidance and skill during medical crises or disease management. It doesn’t mean you can’t or won’t cry with them, it just means they don’t need that, they need you to be an expert.

    Yes, you’re going to get things wrong all the time, that’s the joy of being a student – hopefully you can’t harm anyone. Occasionally you may be the person that saves someone because of the time you take with the patient, and the methodical exam.

    And yes, you’ll be forever changed. That’s what life and death does to people – all people whether military, first responders, health care, caregivers, or just people who’ve lost family members and loved ones. Find a hobby that you love and can lose yourself in it periodically – art or woodworking or gardening or skiing or reading Harry Potter. You still have a soul and it needs to be nurtured.

  • RenegadeRN

    I agree with you 100%, but be careful it doesn’t end up stressing you out and burning you out.

    We put far more emotional energy into our work when we are SO conscious of doing all perfectly for everyone, especially ourselves. You can easily grow to feel kinda resentful with others you perceive as just doing the minimum. It’s a self defeating behavior, to a degree.

    Not to say that doing your job with compassion and integrity is EVER wrong, but perfectionism can also bite you in the butt emotionally. It is my personal Achilles heel, but I have made great stride! Best of luck to you, I think you will be a wonderful physician!

  • Abigail Schildcrout

    To the anonymous author of this post:

    Dear Colleague and Friend,

    I am sorry for your pain. I have written a full response to you in a blog post this evening (www dot DocThoughts dot com). You are not alone.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Wow! 2.2K shares. Anonymous really hit a nerve. Great job!

  • RenegadeRN

    That sounds awful!
    Very sorry to hear that no one sympathetically took you aside and explained what was proper and “clean enough” versus terrorizing you into possibly over cleaning and falling behind (in their eyes) on your work.

    Such a shame there is a major loss of common decency and civility in healthcare these days!

    Was it really necessary to harrass you like that? NO. Was it really necessary for my preceptor to belittle my learning process as a nurse new to ICU? NO.

    Just my 2 cents…hope you are in a new job and doing well Cristian!