• A
  • |
  • A
  • Text size

Has Medicine Lost Its Compassion And Humanism?

In the June issue of the GME e-Letter, we referenced an essay in JAMA (extract) by Paul Rousseau, MD, who observed attendings, residents, and students on hospital teaching rounds from the perspective of a caring family member:

I have no doubt that as the medical team approached her cubicle, she was simply the 52-year old scleroderma patient in the intensive care unit.

She was irrelevant; her disease was not. While she was receiving the best technical care in the world, the individual that she was seemed forgotten, her personhood tossed to the side in lieu of the intricacies of pathophysiology.

Dr. Rousseau's observations lead to a series of questions about our profession:

Has medicine become such a business that the human factor has been relegated to the trash heap? Has the paucity of autonomy or even a falling income usurped the humanistic qualities of our worthy profession? Could it be that we lack empathic and compassionate mentors to plant humanistic seeds among young, impressionable physicians? Are we simply selecting the wrong people for medical school? Or does the rigorous training that ensues during the residency years generate an emotional egress of what attracted us to this principled and honorable profession in the first place: to relieve the suffering of a fellow human being, be it physical, social, spiritual, or emotional?

In his summary, he challenges us "to return medicine to its Oslerian and Hippocratic roots, roots that care for the patient in all domains."

We asked readers of the e-Letter for their thoughts on the essay and whether modern medical care has lost its way and, perhaps, its soul. Below are the responses we received, with identifying information removed.

Note: These views may not necessarily reflect those of the AMA.

From my own recent experience in residency (2006), I believe the "emotional egress" is multi-factorial. We most certainly lack empathic and compassionate mentors. While some do exist, they were certainly not the norm in my training institution. Screaming, yelling, demeaning, sarcasm, put-downs and "one-upmanship" were the norm for attendings and residents, in all of the specialties I saw represented in my large university training program, from medical school through residency. I would not talk to an animal the way these people habitually talk to young, impressionable doctors who are learning from their respected attendings.

The rare kind, thoughtful, professional, courteous, attendings, who treated students and residents like humans, and considered the patient's welfare, rather than just their lab values and X ray reports, were demeaned by the sarcastic ones, as being incompetent or "not assertive."

My husband and I discussed this frequently. Many of the attendings were some of the most dysfunctional people it has ever been my misfortune to meet, let alone to work with. My husband was astounded. He has been a top-level businessman for years. He said that the behavior that was common in my university "would never be tolerated in the business world." One of the instructors, who sees people from the beginning of medical school, all the way through residency, remarked on how often "nice kids become real jerks" as they progress from medical school through residency. However, we are seeing fewer and fewer "nice kids" to begin with.

I think we are selecting the wrong people for medical school. Most of the medical students and residents I saw were selected only for grades, nothing else. Many of them had terribly dysfunctional personalities. The huge majority have no social skills. They have been brain-washed into believing in their own superiority. They have studied books, but not humanity. Many of these students were remarkable for their lack of compassion: "Gunners," aiming only at the best grades, knowing that the more they denigrated their fellows, the better their own chances at acceptance in medical school, good grades in medical school, and obtaining a desirable residency. There is no cooperation, no sportsmanship, no comradeship. If you can knock your competitor, you have a better shot at your own aspirations.

The rigorous training in residency has some good aspects, but it makes the patient become your enemy. The 80-hour weekly work limit is honored far more in the breach than the observance. When you have been up for many hours, your bed is nowhere to be seen, but the "silly" needs of a patient keep you from a precious, stolen hour of sleep. This tends to make the patient an annoyance, a bother, something to be dismissed, rather than thoughtfully considered as a suffering fellow human being.

An example: one night I was on call, covering 50+ patients. Interns were supposed to cover no more than 20 on-call patients, but that rule, too, was never followed. I was told, "If the nurse calls for pain meds for Mrs. Doe, just give her more pain meds. The woman is a drug seeker." It was a terribly busy day and night. Sure enough, about 4 a.m., when I had a chance for maybe an hour of precious sleep, the nurse called about patient Doe. I considered ordering more pain meds, but I had never examined that patient. I sighed, and went to check on her. The "drug seeker" had an acute abdomen. I called the surgical resident, and the woman was soon in surgery. What if I had simply given more pain meds? In the morning, I was congratulated for my "strong work."

Many times during my residency, residents were admonished if they dared consider being "sick." It was a personal failure and lack of ethics to be sick! As an intern I contracted strep from a pediatric patient. My attending, an infectious disease specialist, diagnosed me, ordered antibiotics, and told me to take off till I was no longer febrile. For following my attending's orders, I was strongly criticized by my senior resident as being "unethical" and "lazy,” even though I had previously been congratulated and received top grades for my hard work! As evidence of his own commitment, he proudly boasted that he had worked "with an IV giving me fluids for 24 hours." This was in a medical rotation, not a surgical one.

During my entire medical school and residency training, I found that nurses, by and large, were much more observant and compassionate. Physicians were not compassionate with each other or with patients. "Being first," no matter the cost to others, and lack of consideration for others, is imbued early in their experience, and there is no going back. The patients are "numbers" or "cases." Far more often, the nurses seemed to regard the patients as humans with needs and emotions.

At the same time, I do want to express that I enjoy medicine, I enjoy patients, and I enjoy my practice, but it was a rough journey here, and it would have been very easy to have become jaded and hostile. I asked one of my friends, when she finished residency and began her practice, "What's the most notable thing about being out of residency?" Immediately, she replied, "Nobody is yelling at me!"

I try to impress upon anyone who wishes to become a physician that the road is long and hard, and they shouldn't become a physician unless no other profession will make them happy. As for myself, I was very grateful for a few wonderful, thoughtful attendings, who encouraged us rather than denigrating us. They were my inspiration, my role models and mentors. They kept me going.

The following statement is so very true. I am neither a physician nor a student; however, the following statement, slightly rewritten, would perfectly represent how my mother felt and was treated toward the end of her life.

She was irrelevant; her disease was not. While she was receiving the best technical care in the world, the individual that she was seemed forgotten, her personhood tossed to the side in lieu of the intricacies of pathophysiology.

I wish I had been able to give this article, or even just the statement, to all of the physicians that treated both my mother and my father so poorly. I am an instructor in allied health, and I guarantee you that no future graduates of the program will leave without hearing, seeing, and discussing this statement.

If only we could all treat our patients and their families as if they were the most important people to us in our lives, I truly believe no patient would be mistreated or feel that they did not matter.

The cost of medical education is so steep that the young physician must make enough money to repay the loans. Further, Generation X is no longer devoted primarily to the work of healing unless it allows for a complete social life. Thus, perhaps we no longer have the ability to identify or even to have a sufficient pool of devoted candidates to fill our medical school classes. Finally, the cost of practice overhead demands seeing more patients than we should, lessening the time to provide the compassionate care all patients deserve.

Sounds to me like like Dr. Rousseau doesn't have enough to do if he worries so much about other people having compassion.

On one hand, it is good to have the viewpoint of a physician as caretaker. On the other hand, it is sad that this is what it takes for people to comment.

Of course medicine lacks humanism. And by a lot. Needless to say, the technical advances help tremendously and we should not but use them as much as needed. But there is no dichotomy, no choice to make. Why must we always pit technically advanced medicine versus lack of human values? Rather, these are complementary, they have different roles. Both are needed. It is true that time constraints make it difficult to spend time talking to families and patients. And the reimbursement schedule is not exactly geared to that. And medicine is already too costly altogether. However, consider these few facts and make your own judgment:

  • The most frequent comments from patients concern the attitude of physicians
  • The most common reasons for lawsuits have some link with the physician's attitude
  • In the most technically advanced medical environments we cure . . . 40 percent of diseases? And that is being optimistic
  • Pain, with its huge emotional component, is the most common complaint
  • What has made the value of our profession as physicians is the ability to deal with very personal issues (and this is not reserved to psychiatrists!)
  • The placebo effect may be unexplained, but it is very real; in the field of headache, it averages 40 percent. That means that 40 percent of pain relief is not due to the medication and very likely relates to the attitude of the caregiver!
  • The initial meaning of the word “honorarium” comes from a time when the physician was honored if good care was given. There was no actual income expectation, and any honorarium received was, again, directly related to attitude

With this in mind, there is definitely ample room for more humanism in medicine. Humanism is actually the best driver for medicine: If one truly cares, then one learns best, cares best, practices safe and patient-centered medicine, and, last but not least, looks for new avenues of treatment with research.

All of us must work at this, not the least the educators among us. But education starts early, and being a caring and responsible citizen (and later physician) starts early in life. 

Along with other members of my family, I have been a patient of a physician in this medical center for at least 18 years. I have seen my internist here at the center at least two to three days a week, passing him in the halls or stopping for a brief conversation, and I know him well.

A few months ago, my son returned home and was in crisis. He needed to be seen by a physician and perhaps get some short-term medication. Without hesitation, I called my physician’s office to see if he could be seen. I also asked if they participated in his insurance, which they didn't, so I tried to discuss payment terms, explaining that I could give a significant deposit, file the insurance claim, and personally guarantee that the bill would be paid.

I was told no, that the amount needed to be paid in full, and I could charge it. I explained that I do not have a credit card, but I personally, a patient of 18 years, would make sure the bill was paid. The response? “No, sorry—credit card charge, or no visit.”

How's that for a dedicated physician? You ask if medicine has changed . . .

I am so old that I remember when patients were cared for gratis—they got admitted to the hospital without insurance. Today, costs and liability concerns have taken the human touch out of medical care, and general practitioners can’t get into the hospital to see patients. Hospitalists work for the hospital, not for the patient.