In the first chapter of his landmark work, Medical Ethics, Thomas Percival calls on physicians to ‘‘unite tenderness with steadiness’’ in their care of patients.
Percival wrote those words in 1803. Today, they sum up what healthcare reform is asking of 21st century physicians: “Patient-centered medicine” requires that a doctor combine strength with compassion. A physician needs courage, fortitude—and great empathy. But, as I suggest in the post below, the hazing that turns medical education into an endurance test does not encourage tenderness. Teaching through humiliation and intimidation only conditions doctors-in-training to develop a “tough hide” as they learn to take abuse without showing emotion.
This is a process that trains young physicians to bury their feelings argue Jack Coulehan, M.D. and Peter C. Williams, Ph.D. in “Vanquishing Virtue,” a superb analysis of the “Impact of Medical Education” published in the journal, Academic Medicine, in 2001.
“The hot-house atmosphere is psychologically and spiritually brutal,” they write, and too often, “students receive little emotional support from faculty” or “role-model physicians.” Instead, students report feelings of paranoia: “I’m always being watched.”
Coulehan and Williams stress that some students survive, spiritually intact: “Certain personal characteristics of the student such as gender, belief system,” and age probably play roles, helping some students escape the most harmful effect of the conditioning. Medical schools that support “family medicine” and offer courses in “communication skills medical ethics, humanities, and social issues in medicine” can help.
Nevertheless, in many instances, a poisonous, punitive culture saps the spirit of young doctors as they learn to “shut down” emotionally.
Little wonder that medical students who have endured this rite of passage resent the idea that nurse practitioners can do the work they do, and should receive equal pay and equal respect when providing the same services. These physicians object, because they feel they have paid very high “dues” to earn the title “Doctor. “
“Physicians have every right to believe that the social utility of their work demands respect, Coulehan and Williams acknowledge.
“However, the duration, rigor, intensity, and abusiveness of today’s medical education also engenders a sense of entitlement to high income, prestige, and social power.” In essence many believe (rightly), that they paid a high price to earn that MD after their name—not just in the form of high tuition ,but in the form of “long hours, deferred gratification, great responsibility–—which then warrant very high benefits in return, the cultural equivalent of ‘‘MD’’ license plates.
This leads to that sense of entitlement,” a belief “that physicians are due a special status in the world of healthcare not just because they have worked so hard, but because they have been so abused.”
While their grievance is justified, a sense of having been abused it is not a strong foundation for self-respect. Nor is it is a good reason to resent NPs. Rather, young physicians should resent a system designed to bully rather than to nurture, and vow not to repeat the ritual when they train doctors.
The Explicit Curriculum vs. The Hidden Curriculum
Coulehan and Williams explore the tension between the explicit curriculum of medical school, and a hidden curriculum, the unwritten code that shapes the values and behaviors of many physicians. “The explicit curriculum stresses empathy and associated listening and responding skills, the relief of suffering, the importance of trust and fidelity, and a primary focus on the patient’s best interest.”
By contrast, the implict curriculum, what they call “tacit learning,” stresses “detachment, wariness, and distrust of emotions, patients, insurance companies, administrators, and the state.” This is how residents learn to survive.
“The tacit socialization process goes on continuously, day after day, throughout medical training. Tacit learning is more powerful than explicit learning,” they write, “not only because it is reinforced more frequently but because it relates to doing rather than saying.” Students learn by example. They learn what their trainers value. And most conform. .
In our medical schools, Coulehan and Williams observe: “Technical skills emerge as fundamental, while interactive skills (if encouraged at all) are secondary. The culture implicitly, and often explicitly, devalues primary medical care and relationship-centered approaches to practicing medicine.”
Today, reformers suggest that patient-centered doctors need to be “open” to their patients—open to understanding their fears and desires, open to putting patients’ wants and needs first, open to sharing decision-making.
Dr. Donald Berwick, who I have profiled in the past, puts it this way: “We will not teach future professionals emotional distancing as a strategy for personal survival .[my emphasis] ’We will teach them instead how to stay close to emotions” that they will need to help their patients survive. Patient-centered medicine is all about focusing on the patient’s well-being.” I would add that when physicians take this as their collective mission, they, too, are more likely to survive. (I will be writing more about this in a forthcoming post on “Physician Burn-Out.”)
The hidden curriculum does not favor sharing decision-making with patients. “In their courses on physician–patient communication, students may have learned the appropriate methods of facilitating or negotiatinginformed consent,” Coulehan and Willimas note.
“These topics are in the explicit curriculum. However, in their surgical clerkships they may encounter a culture in which none of this material is relevant.The surgical residents may think that consent is a formality. Their attending surgeon may boast that informed consent is a farce; he can get a patient to agree to anything he wants—‘It’s not what you say, it’s how you say it.’”
Moreover, “the pace and pressure of work are such that there is no time to spend educating patients or answering their questions. The tacit value system embedded in this medical/hospital culture is contrary to the explicit value system the students learned. Nonetheless, they are immersed in this system during the most crucial months (and, later, years) of their transformation into physicians.”
The Third Year of Medical School
Long-time HealthBeat readers may recall an essay titled “Into the Water—the Clinical Clerkships,” a “Perspective” from the New England Journal of Medicine that I wrote about in 2011.
The piece was co-authored by a third-year medical student at Harvard, Neal Chatterjee, and Dr. Katharine Treadway, who teaches at Harvard and practices at Mass General. Together, they describe how the implicit curriculum teaches students to learn to distance themselves from the sights and sounds that surround them when they move from the classroom to the hospital in their third year of training.
“It is ironic that precisely when students can finally begin doing the work they believe they came to medical school to do — taking care of patients — they begin to lose empathy,” Treadway notes. “Studies have documented the high level of compassion with which students enter medical school and the sharp decline that occurs during the ensuing 4 years. . . Most of the decline occurs in the third year.”
At the time I noted that, “Initially, most third-year students are overwhelmed by what they see and hear—the human condition laid bare. Patients die. Others suffer, and cry out. Some must be tied to their beds. Human flesh is ‘filleted,’ on an operating table.”
In this post I am once again quoting Chatterjee’s description of what he witnessed during his third year both because it is so compelling, and because it perfectly illustrates what Couleahn and Williams are talking about—how “Virtue” is “Vanquished” as the capacity to feel withers.
“I have seen a 24-hour-old child die. Chatterjee reprots. ” I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently’ because I was at home, sleeping under my own covers, when she coded.
“I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.
“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.’ I have said nothing about that incident.
“I have delivered a baby. Alone.”
This is part of the “See One, Do One, Teach One” culture that tosses third year’s in the water, to sink or swim, without regard to what this might do to the student—or the mother and child. (I have written about this in the past, when commenting on a brilliant first-person story published on Pulse: Voices from the Heart of Medicine.)
Here, Chatterjee offers an excellent example of hospital-centered medicine. Rather than hiring nurse-midwives, the hospital lets students deliver babies—without adequate supervision. A culture that aims to “toughen them up” has taught them not to ask for help.
Chatterjee continues: “I have sawed off a man’s leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night.
“I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.” Quite possibly, this was a “preventable” medical error. Chatterjee would see more, and over time, might well learn to accept them.
Inevitably, third year medical students bear witness to more human suffering than most of us see in a lifetime. “As [students] have their first experiences with patients dying, they don’t know how they should respond, whether it’s OK to be upset,” Treadway observes. .
“Responses to these events are rarely discussed . . . most students enter medical school caring deeply, and we actually teach them not to care — not intentionally, but by neglect, by our silence.”
A patient dies, and doctors leave the room, without comment. “We place them in profoundly disturbing circumstances and then offer no support or guidance about what to do with the feelings they have in abundance,” writes Treadway. This, she suggests, is “the hidden curriculum” (the transmission of the dominant culture) or the “professional socialization that alters the student’s beliefs and value system so that a commitment to the well-being of others either withers or turns into something barely recognizable. The impact of this hidden curriculum is profound.”
She quotes Renee Fox, a medical sociologist: “As they struggle, individually and collectively, to manage the primal feelings, the questions of meaning, and the emotional stress evoked by the human condition and uncertainty . . . medical students . . . develop certain ways of coping. They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor.” In this way, the student learns to attend to what Berwick calls “personal survival.”
“They are rarely accompanied, guided, or instructed in these intimate matters of doctorhood by mature teachers and role models,” writes Treadway. “Generally their relations with clinical faculty and attending physicians are too sporadic and remote for that.”
So,, the medical student who learned to distance himself from himself eventually becomes a teacher who distances himself from his students. During his medical training, he also learned to be “wary” of his patients.
I recall Berwick once telling me: “Physicians should not be alone.” I agree. This is why we need to change how we educate doctors.