• Cause and Affect

    One of my first months as an intern, I spent a night on call on what we called the “toddler” service. As this was a children’s hospital, this basically meant I was caring for anyone who wasn’t an infant. Most of the children were there with acute diseases, like asthma or bronchiolitis, but a percentage of the children were older and had chronic diseases, like cystic fibrosis. These kids, unfortunately, were in the hospital far too often, and it was inevitable that you would get to know them quite well.

    I couldn’t imagine how lonely it would be to be a 14 year old in a children’s hospital, filled mostly with babies and toddlers, for days to weeks on end. It still makes me sad to think about it. There was one kid (we’ll call him “Mike”), a really nice one, who we all got to know pretty well.

    One of my many obsessions is video games. While this may make me somewhat less attractive as a potential mate, it often makes me more attractive as a pediatrician. Mike was similarly obsessed, and we could always avoid talking about medical things by talking about the Nintendo 64.

    One night I was on call, and every time I passed by Mike’s room, he begged me to play Goldeneye. But I was an intern, terribly busy, and had to keep telling him no. The look he gave me broke my heart, but there was nothing I could do. Around 2AM, when I was finally winding down and thinking of heading to bed to try and sleep for a couple of hours, I passed his room one last time. He was still standing in the doorway, pleading with his eyes for me to play.

    I’m only human, and, contrary to popular belief, I have a soft heart. So I went in and played with him for an hour. It’s a testament to him that he totally kicked my butt. I was pretty good at Goldeneye.

    At around 3:30, I finally told him I had to go to bed. I dragged myself up to the call room and fell into the bed. Not 15 minutes later my pager went off, and that was the last sleep I’d get. The next day, I was a mess, but I still felt that I had done more good by playing with Mike than anything official or medical I’d do for the rest of the day.

    The next day at work, though, my senior resident pulled me aside after rounds. He looked really serious and a bit upset. I couldn’t imaging what was wrong.

    “Look,” he said, “I have to tell you that there’s been a formal complaint lodged against you.”

    I was shocked. What could I have done?

    “A nurse told her supervisor that you took a video game away from a patient so that you could play it. They were so angry that it worked its way up to the medical director of the hospital. He yelled at the attending, who yelled at me, so now I’m talking to you.”

    I explained how that was crazy. I hadn’t taken the game away. I was playing with a patient, at the patient’s request. I was doing the right thing.

    My senior resident looked skeptical, so I offered to take him to Mike to get the story straight. He said that wouldn’t really do any good. I demanded to know which nurse complained. He told me they’d never tell me. I asked to go back up the chain of command, to get all the parties involved, so that I could explain what really occured. He told me that would never happen.

    I asked to be treated like an adult.

    It quickly became clear to me that no one was interested in getting at the truth; they had no interest in a real fight. They thought I was just going to bow my head and apologize. But I was now truly angry. “What,” I asked, “am I supposed to do to make sure this kind of ‘misunderstanding’ never happens again?”

    My senior resident replied, “I guess you shouldn’t play video games with Mike anymore.”

    I bring this up because a reader of the blog emailed me a new study, entitled “Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents“:

    Empathy is a key element of patient-physician communication that is relevant to and positively influences patients’ health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency.
    The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded.
    Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the “hidden,” “formal,” and “informal” curricula as main reasons for empathy decline.
    The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

    Let me translate this for you. Over the course of medical training, studies show that residents and medical students suffer from a significant decrease in empathy. The authors suggest that this leads to decreases in professionalism and possible health care quality.

    I have absolutely no trouble believing this is so. The story above is but one of many I could tell you about how it seemed like at the same time I was being instructed to be a better doctor, I was being taught to be a worse human being.

    People insticntively think that when I complain about residency, I’m going to complain about the hours or the pay. They both stink, but I was prepared for that. What I was totally unprepared for was the fact that I continually felt I was being taught to keep my head down, not rock the boat, and accept intolerable things. I felt like I was being taught to support a system that was broken, because supporting that system was paramount.

    I felt like I was working somewhere where the people around me would rather I not play a video game with a fourteen year old patient if it might make their administrative tasks the least bit harder.

    I think we have a system that still doesn’t support recognizing the importance of a life outside the office and hospital. I think it’s a system that too often lacks humanity. I think it’s a system that still is supported by a class of workers that are treated as little more than indentured laborers.

    If you think such a system isn’t negatively impacting doctors’ affect, then you’re not only ignoring common sense, you’re also ignoring empirical evidence.

    • You did do the right thing. I bet Mike’s parents think so too, whether they told you that or not. It is a shame that doctors are trained to be unfeeling. I understand the necessity for distancing yourself from your patients but I would hope there’s a way for you to keep your humanity while you’re doing that. From the little bit of your writing I have read, I think you did. Thank you.

    • Hi Aaron,
      Great post — I completely believe your story. But doesn’t it say more about how the side effects of how hospitals are organized than about the problem of loss of empathy through medical education. What I see — and have experienced — is that command power relieves certain leaders of the need to be responsible to their subordinates. I’ve seen this in the corporate world as well, and the military seems to almost take pride in it.

      The problem of empathy loss during medical education is real, I think, but it may have different causes.

    • Ouch! I had some similar experiences with self righteous nurses reporting stuff. I had to take a very sick child to the OR. I went over the anesthetic risks with the mother, including the risk of death. I was then reported by a nurse on that unit, anonymous just like it was for you, that I had told a mother her kid could die. The difference for me was that my staff was supportive. It was still disturbing that a nurse would consider that reportable behavior, and that the nursing administration took it seriously.

      The sad part here is that this affects people when they are still pretty young and impressionable. Along with depleting empathy it also fosters cynicism.


    • People insticntively think that when I complain about residency, I’m going to complain about the hours or the pay. They both stink, but I was prepared for that. What I was totally unprepared for was the fact that I continually felt I was being taught to keep my head down, not rock the boat, and accept intolerable things. I felt like I was being taught to support a system that was broken, because supporting that system was paramount.

      From the outside it looks to me like residency is an anachronism that exists to build fraternity among healthcare professionals. Like training camp for marines or hazing to get into a fraternities. The odd treatment may be to keep you on the side of providers.

      I think that one reason that it can exists is that it is way to hard to get a licenses to practice medicine in the USA due to regulator capture.

      My hunch is that if it because much easier to get a licenses to practice medicine that things would change.

      IMO medicine could be learned on the job combined with individual study by people with just Bachelors of Science degrees. Such a system might select less for ability to do great in school and more for compassion and caring for the patients, which might actually be better.

    • Nice post. I was just reading about this very topic in Roter and Hall’s book, Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits (see the latter half of Chapter 5, starting on page 85 at http://books.google.com/books?id=EPUfBLYh-80C ). They reference many different kinds of studies of this topic over the last few decades.

      One really interesting finding they mention from an ethnographic study in the ’80s by Mizrahi was that physicians interviewed five or six years later “were found to have softened their views of patients to some extent. Particularly those patients who went into private practice, as opposed to academic medicine, had redefined their notion of optimal health care by decreasing the importance of technical and academic expertise and increasing the importance of considering the ‘whole’ patient.” An important contributing factor to the “de-empathization” of physicians may well be the top-down, bureaucratic organizational command structure of the organizations that train them.

      But I still think we should train them well! We just need to continue to redefine the notion of “well”, and perhaps I too idealistically hope that we also take a look at implementing new models for how academic medical institutions are managed.

    • As your inpatient teen begging you to play a video game broke your heart, so does your post pull at this pediatrician’s heart strings. Thanks for sharing here.

      And, so sad that “they” are trying to break you, just as you are trying to help improve your patients’ quality of life. Please keep going with your instincts to do what is right, even when busy, and even when people are not treating you like the sincere adult (adult caring for kids) that you are. Fight the good fight.