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.

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