One of the most cited adages of my medical training has been William Osler’s famous quip: “the secret of caring for the patient is in caring for the patient.”

For those not in the medical field, this may seem trivial and quite obvious. I would agree. Perhaps the exalted status of this adage says less about its elegance and more about desperation to grab onto any poetic description of caring and compassion. The value of compassion is not one formally taught in most medical schools. Most commonly, medical students learn compassion as part of the “hidden curriculum” of medical training, through the gestures, actions, and behaviors of more experienced clinicians. Much of the discourse around “hidden curriculum” exposes looser concepts of empathy, compassion fatigue, and sense of purpose.

The evidence is striking: in a study of primary care physicians, nearly 60% report symptoms of burnout, which is defined as emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment. (1) Many factors contribute to physician burnout: hassles with insurance companies, less time allotted to patient care, and endless paperwork. Another largely unexamined cause is the structure of our training itself. Our current medical system propagates certain values that prevent the circumspection necessary to deliver compassionate care. These dominant values are:

– To understand health, study disease: Of the roughly 10,000 hours of learning in medical school, over 95 % is devoted to understanding and managing disease. Compare this to the required 20-hour course in nutrition, or the 30 hours of preventive medicine, and you get the picture. Medical students learn in a system that defines health as the absence of disease. When we fail to contextualize illness within the context of an individual, his family, and his community, we lose a large part of what it means to provide compassionate care.

– Learn disease now, advocate for patients later: Competency of medical students is primarily based on knowledge of disease processes and management strategies. For example, if you are taking care of a patient with Hepatitis C, you should be able to explain the pathophysiology of hepatitis, when to order a liver biopsy, and indications for transplant. To ask the question “How will this patient be managed in the community?” or “What is the best strategy to discuss prevention?” are valued, but not expected. If you are working on a particular hospital ward for three weeks, you have little time to explore the intricacies of care for such patients. I have heard from many medical and non-medical friends, “Well, when you get your MD, then you can start to think about systems-level change.”

Unfortunately, the current structure of most residency programs discounts skills of systems thinking and leadership in favor of flexibility and diversity of experience.  Practically, this means that residents quickly rotate through one discipline before moving onto the next. For the patient with Hepatitis C, this means little time to follow up with them as an outpatient, get to know their story, or explore their barriers to accessing care. Additionally, the structure of the learning environment negatively impacts patient care. In a qualitative study of internal medicine residents, researchers found

Residents admitted to…writing fewer progress notes or deliberately not answering telephones or pages, lying about the status of a test or lab, hiding information, and walking away from situations in which they were needed. Consistent with prior research, many residents avoided asking questions, even when accurate information was critical to patient care. (2)

There is limited research documenting the long-term psychological consequences or educational efficacy of this mode of training. However, studies looking at resident burnout suggest that resident’s graduate with less compassion than when they began. Before reconstructing this system, it is useful to note the assumption that led to such compartmentalization; namely, if we intensely learn about one organ a month, eventually we will be able to heal the patient, and then later, advocate for their disease.

The most striking fact about these values is how infrequently we as health professionals question them. We have restructured our language of health care delivery, but this has yet to permeate into how we train physicians. We can speak of patient-centered care or medical homes, but have failed to structure learning environments consistent with these values. We value disparate disease-specific knowledge over systems thinking, communication, and leadership development, and this choice negatively impacts caretakers and patients on a daily basis. Providing excellent care is more than unlocking a secret. It is continuously evaluating our assumptions about health, reconfiguring systems, and committing ourselves to serve the patient in the widest context possible.

Next week: Systems-level Change in Medical Education

Photo courtesy of Wikimedia Commons, whose photos remain in the public domain.

(1) Krasner, M. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA.
2009;302(12):1284-1293.

(2) Bernabeo, E. Lost in Transition: The Experience and Impact of Frequent Changes in the Inpatient Learning Environment. Academic Medicine, Vol. 86, No. 5 / May 2011