Let's say you know this young woman named Angela. Perhaps she's the niece of your best friend. Angela's a good kid -- never arrested, never even got drunk. Always so serious, too. You weren't at all surprised to hear she'd been her high school class valedictorian, or that she'd been accepted to a top university. You're getting used to hearing regular reports of Angela's greatness. Roundly praised by her professors; gets straight As, and finds time to do volunteer work; has a boyfriend, but she's so focused on her studies that their relationship may be in doubt. Lately, you've been hearing some disturbing things about Angela. She fell in with a different crowd, a group that's taking up all her time. Her mom is worried sick about her. Says Angela lives on fast food and Twinkies, stays up to odd hours with her nose buried in books of arcane lore, never talks to her old friends, and rarely talks to her parents. When her mom does manage to get her on the phone, Angela seems distracted, and often uses language no one can understand. She's learning so much from her teachers, she says; and yet her mother sees her drifting farther and farther away. Her parents had their 20th anniversary last week, but Angela missed it. Said she was too busy to even remember to send a card. Her college boyfriend? He's history. Angela won't even return his phone calls or letters. It gets worse. Her parents hear she's doing things to people now. Hurting them, often with casual nonchalance, and joking about it afterwards with her friends. She has an almost religious fervor when she discusses her experiences -- with dead bodies. She goes up to perfect strangers, asks them highly personal questions, then touches them in inappropriate ways. And she has the nerve to call this a history and physical.
On the very first day of my class's orientation to medical school, we had a formal Grand Rounds presentation. The lecturer, one of our medical professors, presented the history of a young mother recently diagnosed with breast cancer. Her treatment involved a mastectomy and post-operative chemotherapy, and although she seemed to be doing well, her cancer was high grade. He discussed her chances of survival and they weren't great. Throughout the professor's monologue, the patient stood at the front of the lecture hall in a hospital gown and jeans. He finished the history, then asked her to take off her gown so that he could examine her in front of us. After he finished, he dismissed her with a simple thank you. She put her gown back on and exited down a side aisle. The strange thing about this 22-year-old memory: I'm not sure how much of it is real and how much is imagined. I'm certain the woman was present throughout the professor's third-person run-down of her history, but I don't remember if she disrobed. But to me, it felt like she'd been disrobed. Is that why I remember it that way? I also recall wanting to run after her to apologize. I doubt I was the only one who felt that way. A room full of 80 first year medical students on their first day of school, and not one of us ran after her.I'm not the only one to see medical school as a form of cult indoctrination. This link goes overboard, I think, but the author raises several valid points. Nor is the problem limited to medical school: all graduate programs may share this to some degree. That Day One Grand Rounds exercise was not accidental. Head first, we were thrown into the objectification mind set. These are not fellow human beings; they're patients. You care for them, but don't let yourself care about them (except in the most generic sense of caring). You develop calluses, but you must never appear callused. Empathy is not one of your better human qualities; it's a healing tool, and it can be honed if you make a deliberate effort. Most humans don't touch dead bodies, let alone carve them to pieces. Most humans don't ask strangers personal questions, step inside their personal space, touch them in intimate places, stab them with needles, cut them with knives. But us folks in health care aren't most humans.Imagine walking up to someone who is barely an acquaintance -- perhaps you've talked with him five or six times in the past, but never for more than five or ten minutes -- and having this discussion with him: "Your cancer has recurred. Unfortunately, you now have a decision to make. You could undergo a painful and maiming operation which will leave you forever changed, and you might still die from your cancer. You could let the cancer kill you, but it's an ugly death by slow suffocation or, if you're lucky, a quick hemorrhage. Or you could kill yourself." Many doctors skip this conversation. They tell their patient what they should do and leave the second and third options to the patients' imagination. I was taught not to dictate to my patients, but give them all the information necessary for them to make a choice. Consequently, I'm sometimes obliged to have the above conversation, more often than I'd like. But -- damn it -- it isn't natural.
My patients like me, most of them. I've had few angry letters and fewer death threats. When it comes to bedside manner and patient rapport, I get high marks; I play the game, and I play it well. I'm an accomplished actor -- I'm on stage eight hours a day. Medicine is a tight-rope act. Don't care enough, and you're a shit heel; care too much, and you burn out like a Fourth of July sparkler. Sometimes, I think I'm pretty damned good at walking that tight rope. Other times, I want to hop off the rope, run after that young mother with breast cancer, and apologize to her. Like any normal human being would do. D.