I often get patients telling me they feel like I’m really listening, like I really care. Unlike that other doctor, Dr. So-And-So. Sometimes I’m surprised by the name they drop as so many of my colleagues genuinely care about their patients and have, as far as I’ve observed, a good bedside manner. Some patients will always complain, regardless of how physicians behave. We tend to hold our doctors to a pretty high, oftentimes impossible standard. Other times, I’m not so surprised to hear Doc So-and-So has rubbed them the wrong way. Some physicians certainly have a gruff bedside manner. And others, probably more, are nice enough to patients, but don’t really feel the kind of empathy and concern patients expect from their doctor. They follow the script, but you feel like they don’t care the way you want them to. Having spent time behind closed doors with medical students and residents, I can tell you, you’re probably not wrong.
Multiple studies on the empathy levels of medical students, residents and practicing physicians have shown we tend to have less empathy than the average person. One study in the journal Academic Medicine showed that empathy levels actually decrease as medical students move along in their training. Cynicism goes up, compassion goes down.
The widely accepted reason for this is, basically, that medical training is a real bitch. The first two years, where students are taught the science of medicine in a classroom setting, are competitive and stressful. Actually, the words competitive and stressful do not convey what we go through. I’m talking people crying in the halls after exams, weeping and gnashing of teeth. Eating disorders and binge drinking galore. Keep your grades up or get the hell out. I once asked for an extension that I thought was pretty reasonable. My son was in the ER getting IV fluids for dehydration and would possibly need admitted to the hospital and the exam was the next morning. It was the only time I’d ever asked for an extension. I knew leaving sick toddlers at home with my mom, no matter how sad and guilty it made me feel, was part of the deal when I started medical school. I thought the fact he was in the hospital and that I wasn’t one to ask for special treatment might cause them to grant the extension. The professor refused my request and went further. He said, your scores haven’t been that great lately, you’d better do very well on that exam or maybe you’re just not cut out for med school. Damn.
Empathy levels drop even further after the third year of medical school. That’s when you finally start seeing patients so you’d think the battle weary medical students would become more compassionate, not less. That thinking ignores what third year of medical school is really about: pimping. I recall the confused look on my husband’s face the first time I mentioned getting pimped on rotation that day. I’d forgotten the term has another meaning altogether outside the medical bubble. Pimping here refers to a style of teaching employed by attendings with medical students and residents. Oh, how civilized that sounds! The attending, generally an intimidating person who makes no effort to make you feel comfortable in the least, asks you a series of questions about medical facts. A surgeon might ask you to list off the blood vessels and nerves that run through the area he’s currently operating on (as you stand in an awkward, turned and bent over position holding a retractor with each hand). He then might move on to having you trace the blood vessels back to their origins. You’ve just spent two years drinking from the proverbial fire hydrant of medical knowledge, so you search your cluttered, fact-saturated mine desperately looking for the answer. If you fail to produce (which every one of us does at some point), you’re made to feel very small.
As you progress, your wrong answers or, worse yet, no answer at all, move from eliciting comments and looks that merely make you feel like a moron, to comments like, “You’re going to be a resident next year. What if a nurse calls you in the middle of the night with a patient in such-and-such a condition and you don’t know the answer? People’s lives are going to be in your hands. Haven’t you thought about that?”
This is part of the explanation used to defend pimping. If we’re going to be in high presure situations with patients’ lives hanging in the balance, then hadn’t we better learn to deal with pressure? I’ve yet to see the research showing that idea is valid and I doubt I ever will. Because it’s not. What I do see is the culture of physician training where change is resisted and the hierarchy fiercely protected. New doctors really ought to show appreciation for their suffering. It’s how mere humans become physicians.
I have to admit, I’m guilty of it myself. My residency recently moved from 24 hour call shifts to 12 hour ones. It really bothered me. I mean, really bothered me. And I couldn’t figure out why. We know from the research that sleep deprived residents make more mistakes in patient care and also get in more car accidents on their way home. The work hours of residents have decreased in recent years as new guidelines were instituted. We cap out at 24 hours of direct patient care now (no more 30 or 36 hour shifts). First year residents aren’t even allowed to work 24 hour shifts anymore. There’s also a minimum number of hours you must be given off between shifts and a weekly cap on total hours. (An average of 80 hours per week over a four week period). We’re also supposed to have at least one 24 hour period off of work each month. Are these guidelines followed to the tee across the board at all residencies? Oh hell no. But, the point is, the times they are a-changing. Now, back to me and my own old fashioned ways. I was really bothered by the end of 24 hour shifts at my residency and I couldn’t figure out why.
After much soul searching, and many discussions with my fellow residents (none of whom minded the change at all) that ended with “You’re seriously not upset? Really?!”, I came to realize I was so upset because it took away some of what makes being a physican special. There aren’t too many professions out there who work 24 hours shifts on a regular basis for several years straight. Residency is grueling (and mine is one of the kindest ones out there) and people know it. For me, we endure this because medicine is a calling. Not just a job or career or profession. I wouldn’t give up so much time with my husband and children for a mere career. I wouldn’t ask them to make the sacrifices they do for my profession. I do these things because I have been called.
There is no clocking out when you’re a doctor, especially not during residency. I remember the time intern year when I needed to talk to the family member of a patient about placing the patient on hospice for her terminal condition. I’d been there since 6am when I placed the call to the patient’s son at 4pm that afternoon. I’d already spoken to her older son and he felt hospice was the best thing for her, but he wanted me to talk to his brother and him together before making the decision. Her younger son was audibly upset as I told him what I needed to discuss with him. His mother hadn’t been doing well for a while, but who’s ever ready for their mother to die? He told me he was at work, but he would be getting off at five and could come over right after. I was supposed to be done at five o’clock, barring any disasters (always a possibility when you’re working inpatient service), but I told him I would wait. He said he worked about twenty minutes away, maybe half an hour with traffic. I was missing my babies, ages 8, 6, and six months and I knew they were missing me (not to mention how my mom, the one who’d been watching them for twelve hours, felt). But I also knew this family needed me to stay. This was not something I could sign out to the intern coming in to begin night shift. This was something I needed to do for my patient.
Traffic was heavy and then there was an accident. He didn’t make it in until 6:30. I sat at the computer in the ICU, going through emails, finishing up notes from the day’s admissions, waiting. He eventually got there and apologized for being late. I told him he didn’t need to. And I meant it. We talked about his mom’s condition, about their options. Her sons talked about what they thought she would have wanted. The younger son cried on his wife’s shoulder. And then they made the decision to make her hospice. They thanked me. I told them how much I’d loved taking care of her and assured them of how loving and brave their decision was.
I left then, headed home to my family. Soon after, the upper year on night shift called to let me know my patient had passed. She lived less than an hour after the uncomfortable BiPap machine was removed and the morphine drip started to make her comfortable. She passed peacefully with her sons at her side. I cried a little, but there was dinner to be cooked and homework to be done. The baby needed a bottle. I needed some sleep.
I look at the changes being made in medicine these days and I worry it is losing its identity as a calling. Family doctors once saw their hospitalized patients in the morning before going to the office. If their hospitalized patients needed something in the middle of the night, they fielded the call. Now, family medicine is being divided into hospitalists and outpatient docs. Small practices expand bigger and bigger, cutting down on the frequency of call for each doc. Graduating medical students look at the lifestyle a particular specialty will provide as much as the kind of relationship they will have with their patients. Will medicine soon be little more than a job? A paycheck you put your hours in for? Clock in, see patients, clock out.
Perhaps this is what the older physicians worry about when they think about giving up things like pimping and 100 hour weeks. And perhaps, in order to hold onto our humanity,we must remember that not only are our patients feeling human beings, but so are the young doctors we train. We are human beings with limits. Limits to what we can do physically and to how much we can take emotionally.
In the end, it is not 24 hour shifts that makes medicine a calling. It’s certainly not the battle scars of impossible exams and pimping. It is the compassion we feel for our patients. What determines if it is a calling is the motivation that brings us to this job with its blurred borders of where it ends and the rest of us begins. You can go without sleep and endure overhwhelming stress with a hardened heart. You can bring this sacrifice and an abundance of medical knowledge and procedural skill to your patients, but if you don’t really give a damn about who they are, you aren’t really a physician. All the technology and constant outpouring of new medical knowledge and developing of drugs doesn’t change what is most important about us. We are healers, much more powerless than we like to admit. If we can serve with a humble heart and keep from doing too much harm along the way, I’d count that a worthwhile medical career. And I bet my patients would too.