I remember going to a lecture as a medical student in 1st semester on the “culture of medicine“. The culture they described was distant, unemotional, restricted and impersonal. The lecturer did not critique these qualities but rather stated that they were necessary for the practice of medicine.
I remember walking out, furious. I was actively furious for weeks. I understood the need for professional conduct and a certain level of healthy objectivity and separating one’s emotions from one’s practice. But I did not buy for a minute that a cold, impersonal approach where you feel no sadness or joy for your patients and do not participate in their journey was right.
How can it be right? The therapeutic relationship involves the healthy use of verbal and non-verbal communication to heal. On the one hand we were taught a “biopsychosocial” model where a patient’s circumstances and personality were key to understanding their illness but this was undermined by elevating an emotionally sterile approach as the be all and end all to the healthcare environment.
The journey that I have seen my peers, seniors, fellow colleagues and now my own students go through has been educational.
I saw people begin to talk about patients as objects. A description of disease. The “biopsychosocial” model was roundly disparaged as being a “wank”- the buzzword combined with an absence of intellectual depth and rigour in its teaching destroyed it. And when you objectify patients, you dehumanise them, lose empathy and refuse to understand why they are the way they are.
We started to see patients as pitiful and pathetic. The obese, non compliant chain smoker was the epitome of this. Why couldn’t they stop eating and smoking themselves to death? What was the point of treating them for a self-inflicted disease? They’d been told multiple times that their behaviour was destructive and yet they persisted in this irrational behaviour.
Metabolic Syndrome X. COPD. Alcoholic liver disease. Diabetic renal failure. All the ills and excesses of modern society.
At the same time, friends in medicine and other courses would defensively insist on drinking, smoking, taking speed, neglecting their health. Many of them were adamant that they’d “heard it all before” and were uninterested in hearing “another lecture” from someone about their habits. Studenthood was full of financial nightmares. Intermittent homelessness. Stress. New relationships.
Patients often didn’t really want to talk to us at length. They would get tired and saw our education as unimportant. We were definitely bottom of the heap in the hospital. The medical teams had little interest in tutoring us or including us or explaining management of patients. Several of my friends were told point blank that a particular unit was not interested in 3rd year students, or that there was no point in them being there so they should just go home. Our case presentations were criticised sarcastically, we suffered verbal abuse in various settings about our lack of knowledge.
At the same time, I ate unhealthily. I binge drank on the weekend. I partied. I briefly social smoked despite my disgust at smoking, having had 6 uncles and many cousins with smoking related disease. I went through a multitude of disasters in dating including a couple of destructive physically and emotionally abusive relationships. I was depressed on and off.
This was a fairly common scenario. I was in no way alone in this. I saw a large number of peers go off the rails in one way or another. Many quit their courses on changed direction multiple times. A few ended up with severe depression or psychosis. Me, I plodded along with dead average marks and somehow crammed enough to get through.
I had no idea what I was meant to be doing or contributing to the system. Attending some portions of the course seemed like a complete waste of time for us, the doctors and the patients. I finally fell detached, just like I was meant to.
It was at some point in the middle of my course that I had a fairly major realisation about how I had lost my way. Empathy flooded back. And the very suffering and joy that I had blocked myself from feeling overwhelmed me. I had a huge amount of guilt about the person I had become. But I was free, alive and it was delicious. I could never go back.
It certainly wasn’t easy. The culture of non-empathy is embedded. I remember hearing new interns loudly crapping on about their awful patients, not realising that the point of “the House of God” was to satirically criticise that behaviour. I remember hearing about how one of our fellow medical students talked very loudly and condescendingly to an old woman who snapped back at her that she wasn’t stupid. I remember being the first doctor in an arrest call as an intern, the patient dying and the registrars joking and laughing about things going wrong and the death.
Similarly this milieu impacts on the work environment. I remember some of the unfair, derogatory comments made about other doctors, patients, nurses on the ward in full view of everyone by senior doctors. Every single doctor and nurse I know has had the experience of being humiliated in front of patients by a senior.
When people are overworked, stressed, unsupported and there is a culture of blame, the effect is multiplied. Certain hospitals are notorious for that sort of environment. Some places support the development of awful behaviour – in particular overconfident, narcissistic arrogance and bullying combined with sycophantic yes-man behaviour to similarly blind and narcissistic bosses. Particular specialities are well known for this mentality. The nicer “weaker” people are blamed and burn out while the bullies prosper.
The idea of empathy and pleasantness as a “weakness” is typical of sociopathic behaviour. What happens when an institution develops a sociopathic personality?
Learning how to cope with work stress, patients, carers, colleagues while being empathetic has been a largely unguided process. It took me a long time to develop healthy, appropriate strategies rather than the ones based on aloofness. Since starting work I’ve been lucky enough to work with some genuinely awesome, inspiring doctors, nurses and allied health staff. I’ve met some amazing people and been fortunate enough to be share their lives and hear about their experiences.
These days I am in a position of responsibility for junior doctors and students. I try my best to be pleasant, friendly, to be interested in them as people and to guide and nurture them. Developing rapport and loyalty and knowledge and a good, happy team is sometimes challenging but definitely fun when you get it right. The difference you make it how everyone feels is fantastic.
And I make time to spend time with patients. I talk to them about their lives and interests an things other than medicine. I learn from what they say. And helping them feels that much more important. When I feel sad, I feel sad. When I feel happy, I feel happy. It’s wonderful.
Things are changing in the culture of medicine and I’m glad.
