Wednesday, April 16, 2014

Becoming Cynical, Part 1

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.

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