The Matter of the Heart

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Illustration by Jennifer Broza

As medicine becomes increasingly specialized, it is more important than ever to train medical students to not only be competent but caring physicians. Nevertheless, many medical ethics courses continue to tend towards presenting impersonal, austere case studies that prioritize taking action and immediate decision making over seeing the patient as first and foremost, a person and not their ailment (5). Hospital culture has also normalized this “professional” detachment; likewise, medical schools now teach students to thrive in an environment where clinical is synonymous with cold and unemotional. This lack of empathy and patient connection may contribute to physician burnout, which is why changes must be made to how medicine is currently taught and practiced. There are a number of innovative programs in the medical humanities that are attempting to bridge the gap between the clinical and the caring.

Physician burnout is on the rise in the U.S, an alarming trend that in part stems from the emotional detachment from patients that medical training can encourage. In medicine, burned-out doctors are more likely to make medical errors, work less efficiently, refer their patients to other providers, and increase the overall complexity and cost of care. In a survey of nearly 7,000 U.S. physicians conducted by Mayo Clinic Proceedings, it was reported that one in 50 planned to leave medicine altogether in the next two years, while one in five planned to reduce clinical hours over the next year (6). What makes the burnout crisis especially serious is that occurs right as the gap between the supply and demand for healthcare is widening: A quarter of U.S. physicians are expected to retire over the next decade, while the number of older Americans, who tend to need more health care, is expected to double by 2040 (6). The competitive numbers that medical schools boast are no guarantee of swelling numbers of future physicians either. Last year, for the first time in at least a decade, the volume of medical school applications dropped by nearly 14,000, according to data from the Association of American Medical Colleges. By the association’s projections, the country may be short 100,000 physicians or more by 2030 (6). With the dearth of healthcare providers, it is more important than ever to address causes of physician burnout.

Imagine you are a third-year medical student, interacting with real patients in a hospital setting for the first time. You are excited to see the science of the classroom be put to work helping people, happy when you find the right answer, sad when you experience your first patient death. You turn to your mentor or your colleague and perhaps they shrug it off, telling you, “You can’t feel for every one,” (4).  Humans are often thought to have limited ability to empathize. Based on this logic, allowing oneself to feel for every patient may quickly lead to emotional exhaustion. Therefore, it is conceivable that stunted emotional responses are manifestations of a burnt out state. However, it is also possible that the converse is true. A recent review of literature exploring the relationship between empathy and burnout among healthcare staff suggests that there exists a negative association between the two (4). There was consistent evidence that as empathy decreased, burnout increased, and vice versa. At least some physicians knowingly withhold emotional responses in certain circumstances. However, by neglecting to enter into the suffering of patients and to experience natural human emotions, physicians may not be protecting but actually harming future patients and themselves. Preventing burnout requires a multilevel approach that includes both structural and individual interventions. Ironically, the widely held assumption that emotional engagement leads to burnout may be contributing to the prevalence of burnout within the medical field today.

For many aspiring physicians, the way they are educated encourages detachment from their future patients. This attitude stems from both the general culture in medical school and the way courses involving medical ethics and dissections are taught. The process of emotional detachment for many students begins with first-year Gross Anatomy. In the anatomy lab, students are “introduced simultaneously to the cadaver, death, nudity, and anonymity, and to both the obligation and prerogative to cut and explore the human body, ” (1). Unsurprisingly, it can be an overwhelming and emotional moment for students, but many fear to express these emotions for fear of ridicule from fellow students or teachers. A common response to deal with the unnaturalness of cutting into a human body is gallows humor. Students may invent stories about their cadaver or objectify the bodies for comedic effect in order to distance themselves from the identity of the donor. In 2013, a University of Pennsylvania study examined what is perhaps the most common coping mechanism seen in the lab: cadaver naming. Two-thirds of the medical students surveyed (1,152 from 12 different medical schools) gave their cadavers nicknames, many of them unflattering references to a specific bodily feature (1). “Inventive naming,” the study’s authors wrote, “allows students to acknowledge the cadaver’s personhood, while psychologically shielding themselves enough to be comfortable with the dissection.” However, this coping mechanism can have negative implications for clinical practice later on. They carry this distance and the practice of inventive naming forward on to actual patients.  For example, instead of referring to Mr. Jones in room 306, a physician might say, “Let’s go see the terminal in 306,” or “Let’s go see the lung,” referring to the patient as their diseased organ (3). Before they’ve ever walked into an exam room, medical students have already learned from dissection that putting space between the body and the human identity is comforting. In the 1970s, medical sociologist Frederic Hafferty conducted a series of studies on the “emotional socialization” of medical students, concluding that the anatomy lab was “a unique emotional test” where students learned “maladaptive coping strategies in clinical settings,”  (2). Instead of suppressing emotions or distancing themselves from the situation, students should be taught how to manage them, which is impossible unless these emotions acknowledge in the first place. The difficulty with anatomy labs in particular is that no one wants to be perceived as weak and will try to suppress their reactions. Thus it is important for instructors to recognize and validate this emotional difficulty. While first-year anatomy labs are an obvious example of the problems with how physicians are educated, they are by no means the only instance of the larger issue.

The attitude of detached concern that anatomy labs encourage is echoed by the overall culture at medical schools as well. In the 1950s, sociologist Robert Merton led a team of researchers at Columbia University’s Bureau of Applied Social Research (BASR) in a large-scale study of the “professional socialization” of medical students. The researchers examined the ways in which doctors’ professional values and behavior were shaped by their training in medical school. The argued that their observations proved that hospitals promoted a distinctly sterile and un-empathic culture and that medical schools trained students to thrive in this environment (2). Stoicism became the litmus test for professionalism, and students felt that their composure was a sign of “progression” in achieving the professional detachment they needed to develop as doctors. However, as time passed, the students in the study began to report they were worried that they were becoming callous or blasé (2). A common sentiment among students was that medical school training worked very hard to beat humanity out of them in favor of professionalism. While academic rigor may be a factor, this phenomenon cannot solely be attributed to the demands placed on students. Equally to blame Merton believes, is what educators now call a “hidden curriculum,” the set of values implicitly instilled in students by their environment. A 2001 Academic Medicine article argued that while medical schools may include lessons on things like listening skills and fostering trust, students are actually learning to value “objectivity, detachment, wariness, and distrust of emotions,” (5). Creating a more empathetic profession is something that requires a long-term solution, one that requires professors to exhibit the values they wish to cultivate in their students.

Many schools are attempting to instill in their students the importance of taking into account the patient’s emotional response instead of only seeing their illness. Physicians have “taught themselves to see this distress and ignore it,” says Jerry Vannatta, a professor of medicine at OU College of Medicine (3). Vannatta teaches a course on narrative medicine, an emerging field that uses storytelling and literature to help physicians learn to better relate to their patients. His students read and write short stories, developing the observational and empathetic skills honed by writing that they will need for the careers. Using comics is also an increasingly popular tool in medical education. Known in academic circles as “graphic medicine,” this approach is part of the field of medical humanities, which emerged in the late 1960s to safeguard medicine’s personal touch (2). Medical humanists argued that medicine’s transition to scientific diagnostics and specialized treatments had jeopardized doctors’ intimate bonds with patients, necessitating new ways to connect with them. Today, American universities have four times as many undergraduate programs in medical humanities—also known as health humanities—as they did in 2000. Many medical schools also incorporate some form of medical humanities into their official curriculum, with courses that explore suffering, resilience, empathy, disability, and death. The classes incorporate visual arts, literature, film, and “pathographies”(stories of illness written by patients or caregivers) into their curriculum. Comics, a newcomer to the field, are an especially appealing way for people to tell their stories of illness. Recent literature has shown how reading these graphic pathographies can be helpful to patients as they navigate illness and the medical system, and also to medical students and practitioners, as they seek to understand the impact of illness on patients beyond the walls of the hospital. Anatomy labs too are attempting to become more broad-minded in terms of the education they provide. Some schools have set up “Donor Luncheons” where the students meet with the family of the donor and learn about their lives prior to the dissection (1). This discourages students from objectifying the body and encourages the students to see the donors as their teachers, in a way. The goal of these kinds of education is to bring to light the realization that patients are more than the sum of their parts, and to teach future physicians must learn to see past physical flesh and bone for the good of both their patients and themselves.

Edited by: Irene Antony

Illustrated by: Jennifer Broza

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