One of my Loves

Last week's New England Journal of Medicine contains an essay written by Katharine Treadaway (Free full text here) that I thought I would share with you. She is an assistant professor at Harvard medical school where she teaches the patient-doctor course.

The essay is a reflection on her goals as the teacher of this course. Most striking, are the points she makes concerning the typical evolution of medical student to doctors:

I watch the second-year students file into the Ether Dome for their first day of my "Patient–Doctor 2" course. For me, this course marks their true entry into medical school. Here, they will refine their history-taking skills, building on their knowledge of pathophysiology and disease; they will learn how to perform a physical examination; and they will touch a living stranger's body as clinicians for the first time. For them, right now, these are just skills to be learned. They do not see how they will be transformed by them.

I remember my embarrasment during my first physical, I did everything wrong. I listened with the stethoscope to the heart sounds, then palpated the abdomen, went back to the stethoscope for lung sounds, then palpated, back to stethoscope etc. I suppose the crackles I heard in her lungs were really just quiet chuckling.

But was I transformed? I am more cynical than ever, more suspicious of others than before and more skeptical about what I hear. This is positive in a sense but it also makes for a negative view of reality. On the positive end, my understanding of the human condition (What people actually go through and endure) is so much greater now.

They do not understand the importance of what they learned last year, because they do not know how powerful they will become, how patients will hang on their words, how devastating a careless word can be. They do not know how they can "do everything right" and still be ineffective because their behavior has alienated a patient who therefore never returns or does not take necessary medication.

I think this point is just so important. It really never occurred to me until I heard my own mother recall what her own doctor had told her. Something didn't fit and so I contacted the physician myself. I learned that hearing is selective, especially my mother's.

Patients have so much respect for everything you say. Sometimes this doesn't come across in an encounter. One wrong word is all they remember. One chance is all you get, choose your words wisely.

Studies suggest that medical students become less compassionate by the end of medical school, that during the process of professional socialization, their original "commitment to the well being of others either withers or turns into something barely recognizable." In between, they have shifted their focus from the patient to their own learning process.

Is this universally true? Of course not. She’s right in that it happens to most medical students and residents. It’s a consequence of feeling overwhelmed with the body of knowledge one must master. It definitely happened to me as an intern. I’d like to think that as a second year it's resolving and that I now see patients as human beings, friends even.

To try to make it real for them before it actually is real, before they think that the entire purpose of taking a history and performing a physical examination is to develop a diagnostic plan and then a treatment plan, instead of understanding that this is only the beginning of caring for a patient.

Oh boy, I’m sure my medical colleagues can agree on this one comment: “Tell us about it!”

This is one of the extraordinary things about medicine, I say: it is an intensely intellectual endeavor, demanding that you learn and understand an enormous body of information and that you constantly update that information as new knowledge becomes available, but it is also an endeavor of your heart. At the same time that you are learning about disease and diagnosis and treatment, you are learning about illness, the patient, and yourself.

You will learn things about others that you could never imagine, good and bad. You will learn about the human spirit things which you will never be able to convey with words. Most importantly, you will learn places in your heart you never knew existed.

You will discover the bright and dark sides of your soul.