Teaching doctors to care: How do we get back our humanity?

May 7, 2001

Medical training robs young doctors of their idealism, turning them into so many empty lab coats, the author argues.

Medical training robs young doctors of their idealism, turning them into so many empty lab coats, the author argues.

It's 3 am. I'm kneeling over the edge of the bed, the side rails digging into my shins. My arms are tired from hundreds of effective compressions. My back hurts from bending. Sweat is steadily rolling into my eyes. My head is throbbing. It seems as if this code has been going on forever, but it's been only an hour.

I'm so tired. My nose is running. Our team has to split up because two patients decided to try to die at the same time. So there are only three of us working to save this man. The odds are against him; we're only one for five in the lifesaving department tonight.

Brown liquid has oozed from the patient's nasogastric tube and covered my shoes, pants, and jacket. I have no idea what it is, but I'm too tired to be disgusted. Maybe I should gram-stain it and send it to the lab for cytology. The laugh catches in my throat, but then it changes to a scream that I must stifle before it escapes. I'm on the verge of losing control, but I can't indulge in that release.

I look at the patient lying under my hands. He seems to be mocking me with unseeing eyes. His mouth is frozen into a grimace in spite of the endotracheal tube. I sense that he's laughing at me as I expend my last ounce of energy trying to keep him alive a little longer.

From somewhere deep inside, I feel something harden. Under my breath, I sneer, "Why don't you just hurry up and die so I can get some sleep?"

Where did those words come from? Surely not from the same idealistic medical school applicant who told everyone who interviewed her that she is a compassionate, caring person. Certainly not from the person who worried that her empathy would make her overly involved with her patients. Somewhere in the transition from college student to physician, I began to lose what I held most dear to me: my humanity.

Fortunately, such episodes during my residency more than 10 years ago didn't permanently damage my ability to truly care for and empathize with patients. Although there were times when I thought that part of me was gone for good. Now I know that it simply went into hibernation so I could survive the rigors of my training.

Many medical schools are changing their curriculum to help students focus on the humanistic qualities inherent in doctoring (see "These programs focus on relationships" in this issue). But these changes are only the first step toward transforming an unnecessarily cruel, monolithic training system that dehumanizes its healers.

Much more needs to change. Despite improvements, medical education and training strip bright young people of their humanity. It frustrates their idealism and creates painful feelings of isolation and, eventually, anomie, the alienation that arises when a person's standards or values are gradually eroded. The anomic person feels unable to relate to others and has surrendered power to a more dominant figure, who pulls all the strings.

Yet, there is a better way—one in which students learn anatomy and patient communication skills at the same time so they understand that the liver they're studying is connected to a human being. It is also one in which medical education does not systematically shame, isolate, disempower, or emotionally deaden its trainees.

The problems begin in medical school with the attitudes that attend cadaver dissection. This is where we begin to think of individuals as collections of organ systems, and also where we learn—through acculturation and peer pressure—not to allow ourselves to show (or even entertain) human feelings like fear or disgust.

I remember feeling excitement and dread the first time we entered the sterile room. Somehow we all knew that, as medical students, it was undignified to show normal human reactions, like revulsion. To steel myself before touching the cadaver, I told myself: "This is no longer a person. It is nothing more than meat and bones for me to learn from." Without this perspective, how could I have picked up the scalpel and dissected the body of a man who once lived, loved, and laughed?

Stripping the corpse of its humanity helped us proceed, but it removed some of my own humanness in the process. Dissection became easier as the weeks passed, because as we amputated limbs and peeled away outer layers, the cadavers less and less resembled real people.

Then we shifted from cadavers to the pathology of specific organs. Each day as we examined a bucket of lungs, hearts, and other organs, we got a little better at ignoring the fact that they were once parts of living human beings. Ultimately, this constant emphasis on disease and organ systems created a fragmented view of the patient.

We became so pathology-oriented, we began referring to patients by their conditions, instead of recognizing them as individuals with a specific affliction. I believe that this is when dehumanization firmly takes root, and young physicians-in-training lose the sense that medicine is about caring for people. That ideal is supplanted by the concept that medicine is about curing illness—no matter what the cost to the patient.

Under different circumstances, our own sense of what's most necessary in healing might have asserted itself, but medicine exhausts its trainees so they hardly have the energy to think independently.

It's not just the hours or the legendary lack of sleep. The rigors of training also effectively deny us the nurturance of social support. Medical training takes precedence over everything else. Who has time to maintain friendships or love relationships? We didn't have the luxury of completing our late adolescent development. And the experience was so intense, it wasn't something we could share with others outside the profession.

The resulting isolation was hard to take. The stress of trying to know everything—despite a finite memory—only added to our frustration and feelings of incompetence. This also had the unfortunate effect of making us lose sight of our roles as patient care providers. We became so focused on fulfilling our responsibilities to our attending physicians and residents, it detracted from our sense of duty to the patient.

Our inadequate training in coping with a patient's death is another problem. The first patient who died while partially under my care was a middle-aged woman who developed gangrene in a foot ulcer that hadn't properly healed. I was the one who had to tell her that her foot needed to be amputated. I had a rush of nerves as I sat with her, but I finally managed to force the words from my mouth.

She began crying and asked me to call her daughter to come and be with her. When I told my resident I planned to call the daughter, he told me to leave that to the attending physician. I reluctantly agreed.

When I learned, two hours later, that the woman developed a massive pulmonary embolus and died, I was inconsolable. I felt guilty about giving her the bad news and even worse about not calling her daughter. It was my fault she had died alone.

I realized I had to find a way to deal with the sadness and self-blame. Like many physicians, I learned to compartmentalize my feelings. Essentially I created a mental "drawer" that I could stuff emotions into whenever something tragic happened. This is what allowed me to maintain a sense of "professional" detachment.

Luckily, there were counterbalances to the pull of dehumanization—such as compassionate teachers. Certain clinical experiences also kept us from being completely emotionally deadened. Even the most hardened hearts could not help being affected by the first baby they helped guide into the world, or when they were on the receiving end of wet kisses from a child they had helped. Moments like these reaffirmed my decision to be a doctor—but they were all too few.

There were many times during the clinical years when I remember wondering whether I'd go into medicine again, given another chance. By then, of course, it was too late to turn back. Sallie Mae and other lenders owned us.

Now that 10 years have passed since my period of "captivity" in medical school, I have a better perspective on what happened to me. I followed the pattern laid out for me by the medical school administration, and emerged as an individual who was split off from her feelings and estranged from her idealism. With the current design of the system, I could have emerged no other way.

That's why I feel so strongly that we must help new doctors recognize and recover from the loss of their idealism, compassion, and even their sense of self during medical school. They'll also need help combating the feelings of frustration, isolation, and anomie that will continue to plague them in some form during the duration of their medical training.

If their colleagues don't do it, who will?