Surviving Cynical School

Katrina Stewart, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Starting Clinical School at a university like Cambridge, where the insides of a hospital are often unfamiliar to medical undergraduates, is a daunting and exciting process. A few months in, I am beginning to wonder if seeing pain and suffering on a daily basis has changed me more than I had imagined it would. Am I beginning to see someone I barely know as an obese smoker rather than a mother or sister? An alcoholic rather than a man in terrible pain? In short, am I becoming more cynical?

According to a number of surveys, clinical students suffer a decline in both empathy and attitude scores during their experience in hospital [1,2]. We often emerge with a more negative attitude towards homeless people, a more doctor-centred ethos, etc. etc. [3,4]. At first I did not believe that I could ever be transformed into one of those doctors who shocked me in my first few weeks - sweeping through the ward with PR examination before pleasantries, or wheeling an inconveniently confused disabled patient out of the clinic before she could ask any more time-consuming questions. I was shocked by a recent incident that showed me just how changed I was.

During my first few weeks in the hospital, I found an elderly lady wandering down the corridor who was smiling at the board of thank-you cards. I had just been dismissed by the team of doctors I was shadowing. They had told me that they had no interesting patients, and that I should head down to A&E and see the man who had just arrived with a wound full of maggots. With a defiant feeling, I decided that I would introduce myself to this woman beside me. I was sure that talking to her would teach me more than gawping at some maggots.

I was right. But I soon felt hopelessly out of my depth as she explained to me that she had ovarian cancer. I had lost a family member to cancer just months previously, and as she described her story I could feel myself sweating and struggling not to show the emotion I was feeling. She became tearful as she described breaking the news to her husband, who was himself dying of cancer at the time. Then she described watching his slow and painful death, knowing the same was awaiting her.

I had not chosen an easy first patient to interview alone. It shook me for weeks afterwards. But what shocks me now is how this experience contrasts with a more recent encounter.

On a ward round last week, I saw a doctor tell a patient that she would not be able to go home that afternoon as planned. In fact, she would have to stay in a while longer as a scan and blood tests had shown that it was very likely she had ovarian cancer. It was the end of a long ward round. I was hungry, and my feet were aching. I barely registered what was being said. A few hours later, I came to take blood from this lady. The FY1 doctor had given me and my partner a long list of bloods to take. I felt useful, I felt important, but I also felt rising panic as I realised it was going to be very difficult to take all of these bloods before our teaching session.

My partner began to chat to this lady as we were taking her blood. I was absorbed with assessing the quality of her veins, and was a little irritated with my partner for starting up a conversation with such a loquacious patient when we had work to do. When I looked up, I was shocked to see that the lady was crying and my partner was comforting her. “I was so looking forward to going home. But at least my husband won't have to see me cry.” This was the end of a conversation that I am ashamed to say I did not catch the beginning of.

Medical students must change substantially before they become good doctors. We must learn how to end or shorten a conversation with a distressed or talkative patient, and how to distance ourselves from pain and suffering so that we can make objective decisions. However, I do not believe that this must come at the expense of our ability to understand our patients and treat them as human beings. I know this because I have met a few amazing doctors who are both efficient and human. I have only recently realised how much hard work and conscious effort that this requires.

References: 

1. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004 May;38(5):522-534. http://dx.doi.org/10.1046/j.1365-2929.2004.01820.x

2. Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med. 2007 Oct;22(10):1434-8. http://dx.doi.org/10.1007/s11606-007-0298-x

3. Masson N, Lester H. The attitudes of medical students towards homeless people: does medical school make a difference? Med Educ. 2003 Oct;37(10):869-72. http://dx.doi.org/10.1046/j.1365-2923.2003.01625.x

4. Tsimtsiou Z, Kerasidou O, Efstathiou N, Papaharitou S, Hatzimouratidis K, Hatzichristou D. Medical students' attitudes toward patient-centred care: a longitudinal survey. Med Educ. 2007 Feb;41(2):146-53. http://dx.doi.org/10.1111/j.1365-2929.2006.02668.x