One of the things I hope to accomplish in this blog is to document my change in perspective as third year progresses. Part of this means addressing the topic of cynicism in medicine, which refers to an unhealthy skepticism towards patient complaints, callous detachment from death and sickness and even, perhaps, nastiness in situations when kindness is most needed. When, during a physician’s education, can this cynicism take root? In the third year of medical school, argues Danielle Ofri, an associate professor of medicine at NYU School of Medicine. As she writes, “Many of the qualities that students entered medical school with — altruism, empathy, generosity of spirit, love of learning, high ethical standards — are eroded by the end of medical training. Newly minted doctors can begin their careers jaded, self-doubting, even embittered (not to mention six figures in debt).” I think Dr. Ofri is absolutely right.
The first of many contributory factors to this change is the way the third year of medical school is set up. Medical students spend weeks or a month in
different specialties and subspecialties, also known as services. In surgery, this may mean spending a month on vascular surgery and then a month on
pediatric surgery. In internal medicine, this may mean spending a month in the Intensive Care Unit and then a month on the Infectious Disease service.
Throughout our training we switch rapidly between different areas of medicine in order to gain a broad understanding of medical pathology. This is a clear
educational advantage. There is, however, a downside.
As students we seemingly establish a deep relationship with the attending physicians and residents, a natural result of spending twelve hours a day
together. We become comfortable with each other’s habits, musical tastes, food preferences, and career ambitions. And then, two weeks later we leave and a
new group of students arrives. Despite the intimate knowledge we have of each other, the goodbyes we say are polite and brief. Next week we have a whole
new group of residents to meet, and we don’t linger. Similarly, the residents will have a new set of students with them. We all learn to avoid the kind of
human attachments which colleagues normally form in the workplace because we probably won’t see each other again.
But it is not just with coworkers where we learn this rapid emotional release tactic. It happens with patients as well. In multiple instances, I switched
services before discovering a patient’s diagnosis or witnessing the effects of a newly proposed treatment. I saw a one-year-old boy in pediatric surgery
clinic with an embryological disorder that required corrective surgery. But the next week I moved to a different surgical service and never saw him again.
On a separate occasion, a newborn child had a kidney problem that needed surgical management. I went into the patient’s room for nearly seven days in a
row, got to know her parents and followed her course closely. But I left for a different hospital floor and never found out what happened to her. A patient
with a psychiatric disorder refractory to many different medications began a new medication. I knew the patient’s story and saw him every day for nearly
two weeks. And then I moved to a new service and have no idea what happened to him.
I find an apt comparison in starting a fascinating and powerfully
moving novel and suddenly having the book taken away as I approach its resolution. Each new story has an equally elusive conclusion as each month or week
comes to an end. Thus, medical students assimilate the need to form loose attachments. We care when we are on a service but let it go when we switch. A
patient becomes a transient learning experience. Though not everything can tie neatly together with a beginning, middle, and end, unquestionably something
is lost in this hurried change. How can any relationship begin when its end is so near and a new one looms so soon?
Dr. Ofri endorses this explanation: “Every four to eight weeks, the students are whisked through a new world: surgery, internal medicine,
obstetrics-gynecology, psychiatry, neurology, pediatrics, and outpatient medicine. This ensures that students have a good grounding in the broad field of
medicine, but it also ensures that any relationships formed — with patients, nurses, senior physicians, or mentors — are serially disrupted. It’s no wonder
that so many students spend the year in a daze.”
It certainly can feel like a daze — more on this in Part 2.
A neurology resident’s blog about the inner workings of the field of medicine and its theoretical, practical, and ethical complexities. [More]
Science, Medicine, and Healthcare
- MedCity News
- The Apothecary (Forbes)
- The New Republic on Obamacare
- The Atlantic, Top Stories in Health
- Unofficial Prognosis (Scientific American) [archived]
- This May Hurt a Bit (PLOS)
- Science Daily
- Nature news
- MIT Technology Review on Biomedicine
- Health Blog (Wall Street Journal)
- Well blog (New York Times)
1984 ABC abscess ADHD Affordable Care Act agonal breathing agonist airway albumin albuterol alcohol aldosterone Algis Valiunas ALS Alzheimer’s disease American Scholar amphetamines amygdala Andrew Cuomo Andrew Solomon antagonist anti-vaccination movement anxiety arteries arteriovenous fistula Arthur Conan Doyle asthma attending physician autonomy Avicenna Avik Roy battle benzodiazepene beta-1 receptor beta-2 receptor bias birth blood blood pressure blush Bordetella Pertussis Boston Review botox British Medical Journal burnout cancer capillaries carbidopa-levodopa carbon dioxide cardiac output cardiovascular system Case Files CDC cerebrospinal fluid chemotherapy chlorpromazine Christopher Tollefsen Civil War CNN code combatants Commentary Magazine compressions computers confounding bias contact precaution controlled COPD CPR CT scan cupping cynical cynicism Danielle Ofri death Death with dignity deep brain stimulation defibrillation dehydration delirium delivery delusions dementia depression detachment diabetes dialysis diastole differential diagnosis dilation diuresis Doctor and Doll dopamine dopamine agonists doppler double-blinded Dr. Watson DSM Duke University Dylan Thomas dyskinesia ECMO edema Edward Rothstein EEG EKG electroconvulsive therapy electrolytes Emblems of Mind emergency department emergency medical technician emergency physician emergency room empathy EMTALA epinephrine euthanasia evidence-based medicine expletives face facial expression family febrile seizures fetal station field hospital fighting death Forbes free will Fyodor Dostoyevsky Galen Gaza Geneva Convention George Orwell glia glidescope glucose Google HACE hallucinations Hamas Hamlet health heart heart rate hemoglobin Henri Dunant hepatitis c heroin high blood pressure hiking hippocampus Hippocratic Oath HIV Holocaust Hopital X hospice hospital gown hospitals How the Poor Die How We Die human humor hyperkalemia hyperosmolar hyperglycemic state hypertension hyperthermia hypoglycemia hypophonia hypotension ICU imaging inoculation inpatient insulin resistance intensive care unit introduction intubation iPhone Israel J. M. Peebles jaded JAMA James Parkinson Jean-Jacques Rousseau Jenny McCarthy Jim Carrey John Adams John Donne John Locke jokes Joseph Bell Julia Joffe Kaplan Kay Hymowitz kidney stones kidney transplant kidneys Kilimanjaro labor labs language of medicine lead-time bias Lenox Leo Tolstoy Leon Kass leukemia Lou Gehrig's Disease Louisa May Alcott lower motor neuron lungs mathematics medical school medical student medicine Medscape Memories and Adventures memory mental illness micrographia monoamine oxidase inhibitors morphine MRI multigravid music Musicophilia naloxone narcan neonate neurology New England New England Journal of Medicine New Jersey New York City newborn night shift NMDA No Joke nonadherence nonadherent Norman Rockwell nurse NYU olanzapine Oliver Sacks operating room opioid organ transplant orthopedic surgeon osmotic pressure otolaryngologist outpatient overdose pain Palestinian palliative care paralytic paramedics Parkinson's disease pathology patient plan patient presentation patient satisfaction Paul Bloom Paul McHugh PCP pediatrician pediatrics Peter Singer pharmacist phencyclidine physical exam physician physician-assisted suicide placenta platelets pneumonia Polio politics postpartum potassium practicing medicine pregnancy pregnant prenatal testing pressure ulcer PreTest preventive medicine prostate cancer pseudoseizure psychiatry Public Discourse pulmonary artery randomized red blood cells reflex renin residency resident rhabdomyolysis riluzole risperidone Robert Louis Stevenson Robert P. George Robert Youngson Robitussin romanticization Ronald Reagan Rounds Ruth Wisse Samuel Shem Saturday Evening Post schizophrenia seizure Sherlock Holmes Sherwin Nuland shoulder dystocia shuckling Smallpox smell smirk smoking social worker sodium specialty specimen spinal cord spleen splenomegaly SSRI status epilepticus STEP 2 CK Stephen Bergman Stephen Hawking stroke Sudden Infant Death Syndrome surgery systole tachycardia Tanzania TechCrunch The Brothers Karamazov The Death of Ivan Ilyich The House of God The New Atlantis The New Republic The New York Times The Public Interest The Sign of the Four third year Thomas Szaz Toward a More Natural Science tracheotomy trauma trauma surgeon trial tumor umbilical cord uniform UNRWA upper motor neuron uterine contraction uterus UWorld vaccine criticism Vaccines vascular surgeon veins ventricles ventricular assist device Vinod Khosla vital signs Wall Street Journal war war crime warfarin Whooping Cough William Osler
- ► 2015 (13)
This blog will contain frequent references to patients and their illnesses. In order to protect patient and hospital privacy and obey the law, I will not mention any significant identifiers for patients or hospital staff. I will ensure their privacy by altering age and gender when necessary, and by describing events only when sufficient time has passed, so that it is impossible for readers to know when a patient appeared at the hospital. I will, however, remain loyal to the facts relevant to these vignettes when they do not come in conflict with the privacy of the people involved.
By way of a warning, some of these posts contain graphic descriptions of medical conditions and procedures. These descriptions may be troubling to some readers, but they contribute an essential component to the full picture of how medicine works.