For those of you out there who are physicians, what were your thoughts and feelings as you entered medical school? Were you excited about learning, looking forward to working with patients? Did you have a sense of altruism and empathy, of generosity and ethics?
And when did those go away?
According to essayist, author, and physician Danielle Ofri, many of the high ethical standards that students begin medical school without are eroded by the end of training. Graduating physicians often begin their careers “jaded, self-doubting, even embittered (not to mention six figures in debt).” Evidence is increasingly pointing to the third year of medical school as the culprit, the beginning of the downfall of empathy and the rise of disillusionment.
The third year of medical school – the entry to the clinical world of medical education – essentially sets medical students up to fail, to become hardened and bitter. Students have just spent two years in classroom settings learning everything from the Kreb’s cycle to acute renal failure to streptococcal pneumonia. A plethora of facts about infections, complications and drug interactions are swirling in their heads. Now add the disorienting clinical world of the hospital with its rigid hierarchies, politics, patient idiosyncrasies, medical errors, insurance issues, and patient care emergencies – and you’ve got yourself a dizzying situation. According to Ofri, “Everything—from the smell of infected bedsores and the insistent clanging of alarms to the foreign language of hospital lingo and the capriciousness of death—serves to create a disconcerting world. In the midst of this are the greenhorn medical students, acutely aware of their lack of practical skills to do anything of use.”
Furthermore, third year medical students begin new “rotations” every four to eight weeks in the various specialties within medicine: surgery, internal medicine, obstetrics and gynecology, psychiatry, neurology, pediatrics, and family medicine. The rotations were designed to teach students the ins and outs of each specialty and to have a “good grounding in the broad field of medicine”, but these rotations often occur in drastically different settings. Just as students have figured out the daily routines, where the bathrooms are, and how to use the medical record systems, they are whisked away to the next rotation. The rotation changes also give students face time with many different providers, but those relationships are cut short on the same rotational basis.
And students are not only learning the official curriculum. As keen observers trying to soak up as much knowledge as they can, students all too often learn the underlying hidden messages that senior physicians and residents display through body language, patient communication, and staff interactions.
On a daily basis, the students witness fear, anger, grief, humiliation—in patients and doctors alike—all of which are largely unacknowledged. They see egos rubbing up against each other, hierarchies at play, bureaucracies in action. They observe that many of the niceties of patient care fall prey to the demands of efficiency and high patient turnover. Much of what they learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.
The system is designed to generate a new crop of physicians that are just as hardened as the current crop. The next logical step is to change the system, and as Ofri points out, there are a few pioneering medical schools who are doing just that.