White Coats: Can We or Should We Learn Compassion?
September 17, 2010 8 Comments
An article written by Dr. Sally Satel in The Wall Street Journal today, Physician, Humanize Thyself, discusses the origins of the white coat ceremony. In the 1980s, as insurance companies placed increasing pressure on physicians to minimize visit time and maximize patient volume, the medical profession at large became increasingly cynical and disgruntled. A direct result of this was the White Coat Ceremony, whereby each medical student goes up on stage to receive his or her first white coat in front of physicians, classmates, and family. Many US medical schools initiated this movement in the 1980s in an attempt to remind the emerging physicians of the importance of their role as compassionate, empathetic healers.
Does the ceremony work to encourage compassion? The short answer is no. It represents a ceremonial celebration for medical students as they move forward in their careers and enter the patient care setting for the first time. It represents a time when colleagues, faculty, and families come together to celebrate the achievements of medical students. But if we believe that, at times of frustration in the hospital, medical students will look back on this white coat ceremony and remember compassion, we are far too idealistic. I agree with Dr. Judah Goldberg, who is quoted in the article as saying, “To the extent that empathy can be taught through a ritual, a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat.” He is absolutely right: the single best way to get medical students to think about illness in a compassionate way is to put them in a hospital gown. Haines had the right idea in the film The Doctor, a story about surgeon Dr. Jack (William Hurt) who, after being diagnosed with throat cancer, is forced to view medical care from the “other” side. At the end of the film, Jack instructs all of his interns to put on gowns: they are to be patients in the hospital for the next 24 hours. Blood draws, hospital food, physical exams – they are going to experience it all, hospital life in full, from the disempowered and vulnerable viewpoint of the patient.
In my experience, routine visits to the hospital or doctor’s office remind me what it feels like to be a patient. In general, the feeling is not good. I find that I am much more attentive to my patients’ needs after a visit like this, when my memory of my own experience remains vivid and fresh in my mind. Compassion is an important part of the physician-patient relationship. How do we achieve this? We need to listen, to comfort, and to respond to our patients’ needs. We need to care for our patients rather than their illnesses. We need to envision our patients as people and not as a laundry list of medical conditions. This last task, perhaps the most important, is also the most difficult. When we care for people day in and day out who are dressed in hospital gowns and are not feeling well, it becomes too easy for us to forget that these patients are individuals who have a full life outside of the hospital – a life about which we know very little.
A new trend in medicine is to admit students who have a degree in liberal arts. Satel mentions that some schools, like Mount Sinai School of Medicine, even admit students who have not taken some of the requisite science courses or the MCAT. Students who majored in the humanities can certainly bring a different perspective to medicine. But there is no guarantee that we are admitting students who will become compassionate physicians. Why not?
1. We cannot predict how medical students will change during their careers. It is widely acknowledged that physicians become increasingly cynical as they move forward in their careers. This cynicism is particularly evident in a field like emergency medicine, where physicians often become frustrated with caring for patients who are not linked in to our health care system. Many do not have health insurance or a primary care provider, and thus cannot follow-up appropriately. Some roam from emergency department to emergency department looking for pain medication or some inadequate, less expensive substitute for longitudinal care.
2. We cannot necessarily change someone’s inherent personality, nor can we discover it through the medical school application process. Even if we argue that certain people are inherently compassionate and that these are the people who should be trained for the job, we cannot necessarily judge which applicant is more compassionate than the next based on the limited information in a medical school application. One could argue that students on the pre-med track are inherently selfish, at least to some degree. They have many requirements to fulfill and spend much of their time in college achieving – in the classroom, in the research lab, and in their volunteer activities. Just because someone has a long list of “compassionate” activities on a résumé does not prove that they are truly compassionate. And even if they are, the argument becomes circular when we return to number 1 above.
3. The last point, and this one has more speculation involved, is that perhaps compassion is not the most important quality for a doctor. Doctors need to strike a balance between distance and intimacy. To disregard all physician-patients boundaries would likely make patients feel uncomfortable and physicians feel emotionally drained. Already, the statistics on physician well-being are not reassuring. Depression is at least as common in the medical profession as in the general population, affecting about 12% of men and 18% of women. Depression rates are higher for medical students and residents, with 15-30% screening positive for depressive symptoms. All of these numbers are likely lower than the real percentages due to under-reporting (there is significant stigma among medical professionals about psychiatric illness). After accidents, suicide is the most common cause of death among medical students. Suicide rates are higher among physicians, 28 to 40 per 100,000, than in the general population, 12.3 per 100,000 (Council on Scientific Affairs: Results and implications of the AMA-APA Physician Mortality Project, Stage II. JAMA 1987; 257:2949-2953). This is partly due to the higher success rates of suicide attempts. This data is from an eMedicine article written by Dr. Louise Andrew, entitled Physician Suicide. A perspective article by Schernhammer in The New England Journal of Medicine, Taking Their Own Lives — The High Rate of Physician Suicide, discusses some of the problems which lead to physician suicide.
Ultimately, the successful physician finds a balance between compassion and emotional distance, and he is thus able to continue his practice and live happily. But this is easier said than done, especially for physicians who are struggling through their years in residency. Perhaps a lack of compassion is our own survival mechanism.
The issue of compassion is much more complex than it seems. And I have only addressed the physician side of things – the patient side adds an entirely new dimension to the dilemma. Patients have different preferences about the degree and nature of compassion which they expect to receive from physicians. Compassion is undoubtedly an important aspect of the physician-patient relationship, but how important and in what ways is somewhat controversial. Furthermore, if a physician acts compassionately towards his patients without feeling compassionate, is this sufficient? Perhaps the act alone will suffice, if it is performed well. But to disregard compassion completely, to treat our patients as Dr. Jack initially did in the film, would be to fail as a physician and healer and to disregard a critical part of the physician’s calling.