I am not a doctor. (Yet.) I am a novice third-year medical student, somewhat able to perform and document a physical exam on a sleeping child, to dial the correct number to call a consult and to make wild guesses about chest X-rays (“I see a consolidation?”). I write about medicine not from a position of experience, but of malleability. I want to become like the best doctors I see.
Towards that goal, so far, so good. My first rotation in the hospital confirms the stereotype that pediatricians are among the nicest and most patient doctors. Indeed, I am already cataloging the dialogue on morning rounds of the senior doctors answering every question posed by parents, often staying behind to discuss those questions at length no matter how trivial.
But it is the dialogue in the team room after rounds, when the students, residents and attending doctors write notes, order medications, call consults and do whatever else doctors do, that I wonder about. Here, we are free to joke about how long the parents talked, how terrible it is to be yelled at for trying to do the right thing, how difficult people can be. These are natural and predictable things to feel. But is it wrong to talk about them?
I am not offended by the way that we talk about patients behind closed doors, but I am affected. I want to laugh along. I want to see things the way that my superiors do: This is an extra nipple, not a birthmark. This is a lab value to worry about, and that isn’t. This is a difficult patient.
What’s in a name, a label? On the one hand, a label conveys vital information. If a patient is disgruntled, it certainly behooves the doctor to know about this beforehand and try to understand why. On the other, labels can be value judgments. Difficult is not, in my estimation, a character trait that people aspire to have or to encounter.
The other problem with labels is that it becomes hard to see past them, especially when they are part of an otherwise respected and majority opinion. Imagine being romantically interested in someone and then hearing all of your friends describe that person as a loser. Is this so easy to forget? (Show me someone who doesn’t care what others think, and I’ll show someone who doesn’t use social media.)
Some argue that gallows humor is an essential coping mechanism in medicine, and I don’t disagree. Of all the ways to function in the face of suffering, bureaucracy and personal sleep deprivation, humor is probably the healthiest. But it isn’t harmless to joke about a patient’s concerns or temperament, either, unless it’s possible to laugh about someone out of earshot and then genuinely care about that person when face-to-face.
It is the practical impact of laughing about “difficult” patients, not moralizing, that concerns me. I genuinely believe that physicians should be allowed to decompress, to laugh, to have opinions — in short, to be human. But we must be mindful of our other human instincts, namely towards conformity. While a functioning team is essential in medicine, it cannot come at the expense of patients, even though commiseration over “difficult” patients is often a quick and salient bonding point.
Instead, I propose applying the principles of cognitive behavioral therapy (CBT) towards increasing empathy for patients. The basis of CBT is that thoughts engender emotions, and that by altering our thought patterns, we can change the way that we feel. (For instance, instead of assuming that your friend is late because she’s inconsiderate, consider the possibility that something came up. Until the friend arrives, you have only self-constructed thoughts about her whereabouts; the former elicits a negative reaction while the latter promotes equanimity.) In regards to “difficult” patients, doctors can break the habit of referring to them as such and make a conscious effort to avoid value-judgments: Saying, “He’s very concerned,” versus “He talks too much,” for instance. It’s subtle, but we can train ourselves to empathize both inside and outside the patient room.
Professional culture runs deep, and it starts both from the top and the bottom. As a student in a very hierarchal field, my reflex is to emulate my superiors, for better or for worse. I wonder what I’ll say and how I’ll feel when I too am overworked and overwhelmed. But habits start early. I vow not to call my patients difficult because there’s nothing easy about being sick.
Weisheng Mao is a medical student.
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