People enter the profession of medicine for a variety of reasons. Certainly self-interest often plays an important role in somebody choosing to be a doctor. Prospective physicians are well aware that at the end of a long road of education and training, there is the virtual guarantee of a reliable, respectable, and sometimes lucrative job. But it is also the case that many doctors-to-be are motivated by the desire to help their fellow human beings. Entering medicine holds out the promise of becoming a healer, of engaging in work that really betters the lives of others.
It is a sad fact that medical students seem to lose a significant amount of this altruistic impulse as they progress through their medical training. Physician and essayist Danielle Ofri writes that
something in our medical training system serves to stamp out whatever empathy students bring with them on day one. The research appears to conclude that it is the third year of traditional medical curriculum that does the most damage. This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care. For most students, the third year of medical school is eagerly awaited. After two long years sitting in classrooms, you get to actually do what it is that doctors do—be in hospitals, take care of patients. One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place—idealism that is sorely tested in the first two years of memorizing reams of arcane facts.
But the reverse seems to occur. After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered. Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine. And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians.
Ofri goes on to consider why the clinical years of medical school tend to undermine students’ compassion and empathy. The most frequently identified culprit is what is often termed the hidden curriculum. Ofri writes that
the formal curriculum—what is taught in the lecture halls, what is embodied in the school’s mission statement, what is intoned by the deans and senior faculty who usher the students into the sacred world of medicine—can be trounced by the hidden or informal curriculum that the students are submerged in once they enter the clinical fray.
During the clinical years of medical school, students spend most of their time with interns and residents. These are physicians who just finished medical school and are now receiving intensive training in whatever specialty they selected. These interns and residents from whom students receive most of their training are usually expected to perform a large volume of clinical work in a brief period of time. Thus, as Ofri writes,
these physicians-in-training typically develop a whatever-it-takes-to-get-it-done attitude” that “breeds an efficiency that often dispenses with niceties. . . The primacy of pragmatism laced with gallows humor and ever-present physical exhaustion submerge the idealistic medical students in a decidedly unromantic view of medicine. The philosophical musings of Osler, Hippocrates, the deans, and the old-school attendings have little traction here.
The medical student observes that even the most thoughtful and humanistic intern operates under the brutal calculus that every minute spend on nonessentials simply prolongs the work. Sure, it’s wonderful to have an in-depth conversation with a patient, to do a more thorough physical exam, to patiently explain the disease process to a family member, to read up on a rare disorder, to attend that lecture on communication skills, to visit a patient a third time in the day, to make those extra phone calls to unravel a patient’s medical history, to let a patient ramble on without interruption—but none of these will get the work done. . . Whatever the medical student has been taught, and even genuinely believes, about the ideals of medicine, the primacy of empathy, the value of the doctor-patient relationship—all of this is swamped once he or she steps into the wards. Even the most idealistic student can start to view every new admission as an additional burden, every patient’s request as another obstacle to getting the work done, every moment of casual conversation as a moment less of sleep. It’s no wonder that empathy gets trounced in the actual world of clinical medicine; everything that empathy requires seems to detract from daily survival.
As part of the task force designing the bioethics and humanities curriculum for the new Dell Medical School in Austin, one of my goals is to bolster medical students’ moral resilience. I want to help physicians-in-training maintain a moral vision for their work even when a variety of forces threaten to undermine it. In future blog posts, I will consider how medical educators can encourage students to operate with a moral vision in which caring for patients and their well-being is the ultimate, guiding value.