Wednesday, April 21, 2010


If you’re not a medical doctor, please reflect on what it’d be like to become one. After college, you endure four years of medical school and then a varying period of postgraduate training—three years for internal medicine, seven or more for some surgical specialties.

In an earlier post I described how medical training consists of heads and tails: you learn medical science and you simultaneously learn how to be a doctor. Though the latter curriculum, being implicit, isn’t often discussed, its influence is profound and indelible. To be a doctor you need to play the doctor role, which means appearing competent, confident, in control, and to a great degree, clinically detached: in other words, you learn to imitate the popular concept of a scientist. This curriculum isn’t taught in courses, only by example. As a student you learn to behave like your resident, who behaves like the senior resident, who behaves like the department chair. Immerse yourself long enough in this subculture of detachment, and eventually you’ll fit right in.

Keep in mind that this period of training spans from one’s early twenties, when non-medical peers are learning adult social navigation. While my friends from high school and college were marrying, having babies, going on picnics, and getting in trouble and finding their way out, I and my fellow med students were monastically laboring, year after year, within hospital hierarchies, socializing only with one another. It dawned on me in my mid-thirties: blimey, I’m socially stunted!

That’s not just an impediment at parties. It means we docs go into practice never having developed the skill of hanging out informally, without any agenda, long enough to know others deeply. Failing that, many of us aren’t even aware we can deeply know others—or ourselves, for that matter. This can eventuate in a rather desiccate life.

Yesterday I received the quarterly Medical Board of California newsletter. I routinely read it mainly for perverse amusement, as it lists the physicians who’ve had their licenses pulled for having sex with their patients or sewing someone’s elbows together. The lead article in this issue, about physician well-being, was worth reading. It reiterated the common knowledge that “…medical students, residents, faculty physicians, and physicians in practice suffer from burnout, depression, and suicide at rates equal to or higher than the general population.”

That our most highly trained healthcare professionals suffer such dire statistics themselves is astounding, but offers no clue to the sad situation’s source. Interviewed on a recent call-in radio show, I tried to explain how medical training leaves practitioners devoid of the tools they need to cope with the suffering in and around them. A caller screamed that I had a lot of nerve defending the medical miscreants who had abused and damaged him. Having been abused by a couple of docs myself, I could sympathize with him, yet I had to point out that we’re not going to rectify things simply by castigating doctors. Because of their histories, they have little or no idea how they come across to patients. Sure, dissatisfied patients fire docs all the time by voting with their feet. When I asked a colleague, “What do you make of it when a patient who’s been coming to you suddenly vanishes?” he answered, “Well, I guess that patient’s been cured.” To be sure, he had his tongue in his cheek, as though he knew the right answer but wished he didn’t.

There are glimmers of hope. The medical school at the University of California San Diego, for example, conducts a “Healthy Student Program,” offering elective courses in stress management, time management, yoga, meditation, peer counseling training, active listening, and prevention of depression, anxiety and burnout. Students are encouraged to exercise and to participate in social and cultural events.

In other words, the school is aware of the problem and is taking sensible measures. This program and its cousins around the country will have a positive effect, but limited, and here’s why: it contradicts the implicit “how to act like a doctor” curriculum. You can’t teach someone to remain  emotionally detached and at the same time to be introspective, personable and compassionate. And for now, the former is in the driver’s seat.

Literally exclusive objectivity is so firmly incorporated into current medical school faculties that every humane opportunity UCSD offers its medical students is considered touchy-feely frill compared to the traditional solids—anatomy, physiology, biochemistry and pharmacology—and there are only so many hours in the day. A few years ago I was asked to teach an afternoon of doctor-patient relationship to a group of med students. Not four minutes into my presentation, a professor of surgery entered the room, walked right by me, handed quizzes to the students, told them he wanted them done by five o’clock, and walked out. The ambient mood changed radically. I might as well have continued on in Japanese. At least, I thought, there couldn’t have been a more graphic demonstration of current priorities.

Several years ago I dropped in on Eric Cassell, MD, Emeritus Professor of Public Health at the Weill Medical College of Cornell University in New York and the author of The Nature of Suffering. Dr. Cassell is arguably the grandfather of the movement to restore humanity in healthcare. I asked him when he thought the tipping point might occur, when humane contact would outweigh detached scientism.

“Not in my lifetime,” he snapped. “How old are you?”  

I told him. 

"Probably not in your lifetime, either," he said. "But it will happen."

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