There is a very good essay published in Family Medicine written by a physician who had a patient present to the Emergency Department essentially dead from Sudden Infant Death Syndrome. The essayist (who was on his way to teach a group of medical students) initially identifies his conflicting feelings of on the one hand knowing that he could not affect the outcome for his patient but on the other hand feeling like his presence might be of some use to the family. He is amazed at the magnitude of his contribution by the end of the essay.
It was humbling to reflect on how I had initially considered my responsibilities as a teacher more urgent than attending to the death of my patient. I felt ashamed when I remembered that I had thought because the baby was dead, there was nothing to do, no algorithm to follow, no intervention to aim toward an optimal target. Mandy’s and Joe’s loss left me deeply saddened and drained, yet in a strange way, a way that perhaps only other doctors would understand, the morning’s events also rejuvenated me.
He goes on to point out that as a faculty physician, he often preaches the evidence based approach and forgets the importance of ministering to the sick and the bereaved. This episode reminded him of the importance of relationships, a lesson which was lost in the day-to-day work of teaching medical students. He then went to class, apologized for missing the previous class and offered his students a lesson in professionalism and empathy based on his experience. I have observed that students do not understand the importance of these types of encounters. While nothing concrete happened, the essayist changed the outcome of the encounter just by being available. Patients want that level of commitment from their physician. There has always been a tension between the needs of the patient and the needs of the person wearing the mantle “Doctor.” In light of work hour concerns, declining patient satisfaction with the health care environment, and other problems, maybe we should place more emphasis on this aspect of medicine.
Can we teach people to “do the right thing?” Is it important that those of us who teach students understand these types of relationships? Isn’t connecting with people a skill that people ought to bring into medical school? Can it be taught?
If there is a problem, and many agree that there is, partly it may be the selection process. We tend to select wealthy students with exceptional grades who test well. These criteria may not select for empathetic future physicians.
A tendency towards “humanness” may be lost in the educational process. “Hardening of the hearts” of medical students has been described in the literature.
The results of this study suggest that student empathy is affected by medical education. Our study supports the findings of Coulehan and Williams, who described deleterious changes in various humanistic qualities as medical students became “immunized” against these values after their matriculation into medical school.
We may not put forth the best role models. Many academic physicians have a career trajectory that requires mobility. From medical school (4 years) to Residency (3-5 years) to Fellowship (an optional 1-3 years) to junior faculty (5 years) to mid-career leadership role (5 years) a medical school faculty member may have lived in 5 different cities in a span of 20 years. To a physician who has had such a career, relationships with patients likely will take a back seat to other aspects of technical practice such as technical skills. In medical schools such as ours, we combat this through the use of community preceptors for certain educational experiences (such as Family Medicine).
The good news is that it can be taught to physicians, even after graduation. From an article about malpractice prevention:
Practical means of sending a message of respect were identified in a study by Levinson.They include attention to body language (Do you look rushed?), efforts to solicit patients’ opinions (“Which option seems most workable for you?”), and encouraging patients to talk (“What can we talk about today?” followed by a mandatory pause). Such strategies take time. However, in the Levinson study, providers modeling respect-generating strategies averaged just over 3 minutes more per encounter than their colleagues who did not but who were subjects to suits
Can the medical profession do better? Admitting the correct folks into medical school and/or taking the time to assess and correct empathy deficits is important and will lead to physicians who are unable to generate an empathetic response seeking an alternative career path. Having role models among the full-time educators (with a clinical practice that includes continuity patients) such as the essayist may arrest the heart hardening effect of medical school. Identifying community champions of empathetic practice and placing students with these clinicians is important and will counteract the tendency of university physicians to minimize those relationships. Identifying those practicing physicians who slipped through the cracks and offering remediation will improve the situation as well.