The Psychological Impact of Medical Training on Physicians

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.”

                                                Patient-Centered 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.

7 thoughts on “The Psychological Impact of Medical Training on Physicians

  1. #1. Williams is a PhD, not a medical doctor. Therefore his opinion on medical school training is 100% irrelevant. He has no idea what he is talking about. He has never been a medical student, nor a physician.

    #2. Midwife students who have zero medical training and are as young as 18 years old deliver babies solo all the time with no supervision from their supervising midwife who may be stuck with another patient. Laypersons deliver babies all the time on their own with no help. Why are you not going after all the midwives who throw their students into the fire with no supervision?

    #3. I’m sure that we should allow nurses to do surgery. After all, they will sing cumbayah to the patient, hold their hands, and certainly would never do anything as dastardly as “fillet” a patient splayed open on the operating table. BTW, a friend of mine was involved in an auto accident and almost died before he made it to the OR. I’m certainly glad they “FILLETED” him open and threw him across teh table rather than take an hour to sing songs with him or hold his hands before cutting him open and saving his life.

    #5. Renee Fox is a PhD, not a medical doctor. She has zero clue what medical school, residency training, or what being a doctor entails. Her opinion is 100% irrelevant.

    #6. “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.” Ummm this is complete conjecture. Cite your evidence, please.

  2. Jason

    As I note Jack Coulehan is a an M.D., and lead author on the ariticle.

    If you looked at the atrticle and Googled Peter C. Williams, you would discover that he is Professor of Preventive Medicine and member of the Division of Medicine in Society in the Department of Preventive Medicine at Stony Brook University. He teaches and counsels medical students, and so knows a great deal about their experience.
    His knoweldge is 100% relevant.

    Renee Fox has published seminal works on medicine and medical training including ” Training for Uncertainty” which Health Affairs describes here: In her classic essay, “Training for Uncertainty,” sociologist Renée Fox describes the cognitive and emotional development of medical students in terms of what is unknown to them because of inexperience or specialization and what is unknown to medicine as a whole. This set of distinctions has moral and practical consequences for all young physicians. They need to decide when to seek help (and of what kind) and when to recognize that the course of disease can’t be altered, no matter what resources might be brought to bear.”
    Her knowledge is 100% relevant.

    The paper is not based on opinoins, but rather on evidence drawn from medical reserach.

    Your views on what nurse midwives do is, by contrast, an opinion. (Unless you can show me reserach showing that 18-year-old midwives deliver babies in U.S. hospital, unsupervised. A certified nurse-midwife has to have a master’s degree– two years of educatoin beyond 4 years to get an RN., To deliver babies at 18, she would have to start the program at 12.

    Nurse practioners do assist in surgery, sewing patients, etc. Nurse anesthesiologists (another Ph.D. program) also assist in surgery.

    As I noted, when a seven year old who has come in for “elective’ (optional) surgery and dies in a CT scanner,
    “quite possibly” a medical error was involved.

  3. Jason’s comment is a good illustration of the either/or fallacy that one sees so much of in discussions like this. It also goes by the name of black and white fallacy or false dilemma. Our choices are not between an incompetent, compassionate physician and an unfeeling, highly skilled technician. We can and should have both.

    Maggie, you might recall I wrote a little essay for HealthBeat a couple of years back about the Chatterjee NEJM piece that seems appropriate here: http://www.healthbeatblog.com/2011/05/nurturing-doctors-can-empathy-be-taught/

  4. Chris–and Everyone–

    Chris, I looked for the post that you wrote back in 2011, but somehow couldn’t find it. I especially liked the ending:–particularly the last line.

    “We should never again send a resident, alone and emotionally at sea, to comfort a grieving family without backup. We do not do that for complicated invasive procedures; we should not do it for this other, equally important task either.

    “Certainly some organized instruction – seminars, discussion groups, lectures and the like – can be part of the process. But the training curriculum is already stuffed with subjects. Taking residents by the hand and leading them through these experiences does not require another fat syllabus. It only takes a little time. If we want to foster compassion in our students we should ourselves show them compassion for the situations we put them in.”

    I urge everyone to read the entire post http://www.healthbeatblog.com/2011/05/nurturing-doctors-can-empathy-be-taught/

    Reply ↓

    You also offer a history of medical care that helps explain what has happened over time. Back when your grandfather was a doctor, there was relatively little that he could offer except compassion. We had few cures, but doctors did their best to comfort, while hoping that the body would heal itself.

    But then so many exciting cures came along, that they became the focus of medicine. The technology seemed to trump everything else. Meanwhile, many doctors and hospitals began to see death as a failure–an embarassment that we should hide.

    I do think all of us are born with that spark of compasssion–I can see it in my 1 1//2 year old granddaughter comforting my daugher’s `19-year-old cat.

    But I have met 21-year-old’s who seem to have had it snuffed out well before graduating from college.(Too much helicopter-parenting can, I think, leads to solopsism.)

    I do think that med school admissions committee’s need to pay less attention to grades and MCAT scores and more attention to the person him or herself. Perhaps ask him about family: does he have grandparents, or memories of them? If he’s not comfortable talking about such things this could be a red flag. (This may not be a good example, but there are ways to draw people out.)

    A little life experience also may help awaken a self-absorbed 21-year-old.

    I have read that older applicants who have some life experience that involves helping others (Peace Corps, working in a inner city public school etc.) may be less self-involved than the younger med school applicants. .

    • Training compassion out of students has its parallel in the legal profession. I always thought my experience as a law student was based on the elitist, intentionally brutal training of marines. We were meant to see ourselves as a group superior to the rest of humanity for having survived such an experience.

  5. Off topic a bit, but did the healthbeat website address change from a .org to a .com recently? All of a sudden I was having problems accessing this website until I figured that out! If this is a change, can it be emailed out to all subscribers?

  6. NG–

    Thanks very much for letting me know.

    The old HealthBeat was both on heathbeatblog.com and healthbeatblog.org.

    When I re-launched it, I asked the people running the new server to make it “healthtablog.com. (It’ s a communication, not an organization.)

    But perhaps the change wasn’t accepted by the new
    server..
    I will check.