By Meagan Brennan
The focus on patient-centred care has prompted physicians to consider how to better centre the human experience in healthcare. Most patient-centred initiatives ask, “How can we put the humanity back into our medical practice?” Perhaps a better question is “Why did we remove it at all?” Instead of trying to foster compassion and listening skills in doctors who are exhausted and burnt-out, we should help medical students hold on to the values they bring to the profession.
Most students are drawn to a career in medicine because they want to help people and relieve suffering. Before they enter medical school, we require them to write essays, present portfolios, and attend interviews to demonstrate their empathy, compassion and connection with people and their communities. Yet once they are accepted into medical school, our teaching structures systematically dismantle these traits. The hidden messages we send students do not support human connection; they “teach the humanity out.” Here are some examples of the lessons medical schools (unintentionally but explicitly) deliver as well as the lessons that students actually take from us.
Lesson 1: Doctors are Scientists
Traditional medical schools spend two pre-clinical years teaching students about cells, structure, mechanisms, and the pathological characteristics of disease. People are presented as collections of cells and disease as a dysfunction of the body. Students are taught how to weigh up levels of evidence. Randomized controlled trials of thousands of patients (trials large enough to erase individual characteristics) are the gold standard. Any “study” where n=1, such as a patient narrative, is low-level evidence, and should be viewed with caution if not scepticism. In this environment, those with an academic background in science thrive; those with a background in the humanities may struggle but quickly learn to leave their art and philosophy behind and to embrace retraining in The Scientific Method.
The Underlying Message:
The human experience of the diseased body is not relevant to the work of scientists. The individual patient experience is not actual science and does not meet the threshold for evidence.
To Improve:
Medicine should be presented as a discipline at the intersection of art and science. We should draw on the medical students from the humanities and explore how their understanding of humans and society can inform our approach to patients. Every study of a disease process should be accompanied by a patient narrative detailing the experience of living with the illness as well as a physician narrative diagnosing and treating the condition.
Lesson 2: Patients Don’t Speak Our Language
During clinical skills training, students are taught to translate patients’ stories into organized case histories. Patients’ rich, raw, and descriptive words morph into medical terminology, with much of the story lost in translation. Patients’ symptoms are faithfully documented but are not acknowledged as descriptions of human suffering. Clinical interaction focuses on doctors’ need to get through all their questions, preferably in “logical” order. The fast rhythm of the systems review cannot be interrupted. Patients try to please their doctors by providing the requested information (and only the information) but feel disempowered to communicate their true concerns and priorities (Berry et al. 2017). In addition to being a barrier to communication, this “doctor speaks” model increases the chances of a new agenda being raised late in the consultation (Marvel et al. 1999).
The Underlying Message:
The consultation is an interrogation in which the doctor extracts the “important” information, requiring the patient’s often-rambling storytelling to be controlled.
To Improve:
At the beginning of a consultation, embrace the model of “patient speaks and doctor listens.” This allows patients to feel heard and gives doctors an opportunity to show interest and concern, improving rapport and often resulting in better quality information. Listening before speaking is a practical, evidence-based strategy for managing consultation length. A patient in primary care only requires a mean of thirty-two uninterrupted seconds to complete an explanation of their concern. Earlier redirection of the discussion by the physician is associated with more concerns being raised at the end of the consultation (Marvel et al. 1999).
Lesson 3: Never Let Yourself Feel Their Pain
We tell students that doctors need to control their emotions when they interact with patients. We teach them to develop a poker face and not to show stress, sadness, or fear. To maintain composure in all situations. To never cry. To be professional. White coats and hospital gowns help to mark the lines between “us” and “them.” We say that this separation is needed to prevent burnout. In fact, allowing ourselves into the patient’s story facilitates empathy, may improve the patient-doctor relationship, and (by increasing human connection) may protect against burnout. Suppressing emotions and failing to acknowledge distress contributes to the mental burden that doctors experience. After years of turning off emotions, the process of understanding and addressing the cumulative trauma from a medical career can be particularly challenging.
The Underlying Message:
To survive as a doctor you must become unemotional.
To Improve:
We must acknowledge the privilege and joy that walking alongside a patient can bring us. We must use this empathy to sustain us, prolong our careers and reduce burnout. Our care must be accompanied by acknowledging that the things we hear, see, and feel can be painful and vicarious trauma must be managed. We need to give our students the space and the skills to cope, which means senior clinicians must model their vulnerability.
Some medical students recognize the irony of the potentially dehumanising process of medical education. Reflecting on her uncomfortable reaction to “gallows humour” used by a senior physician, a first year medical student elegantly verbalized this rite of passage as “emotional desiccation”’ (Tiskus 2019). She fears compromising her core values as she embarks on a journey that may transform her into someone who could not only see the humour in such a joke but possibly utter similar words herself.
To address dehumanisation in medical education, we must improve both the patient experience and support physicians’ and medical students’ well-being. Medical students come to the profession with a commitment to recognize and reduce suffering. We need to recalibrate our system of medical education to nurture these ideals and to teach clinical skills that focus on the needs of the patient rather than the physician. This approach would be much more successful than helping experienced doctors rebuild their compassion and communication skills, which have been lost as a survival mechanism.
References
Berry, Leonard L., Tracey S. Danaher, Dan Beckham, Rana L. A. Awdish, and Kedar S. Mate. “When Patients and Their Families Feel Like Hostages to Health Care.” Mayo Clin Proc 92, no. 9 (September 2017): 1373-1381. https://doi.org/10.1016/j.mayocp.2017.05.015.
Marvel, M. Kim, Ronald M. Epstein, Kristine Flowers, and Howard B. Beckman. 1999. “Soliciting the Patient’s Agenda: Have We Improved?” JAMA 281, no. 3 (January 1999): 283-7. https://doi.org/10.1001/jama.281.3.283.
Tiskus, Jenny, “The River Styx,” May 28, 2019, in The Nocturnists, produced by Emily Silverman, podcast, https://thenocturnists.com/season-2/2019/5/28/s2-e10-the-river-styx.
Dr Meagan Brennan is a clinician and medical educator in Sydney, Australia. Her interest is promoting human connections in medicine as a pathway to improve the patient experience and physician wellbeing.