By Dr. Jonathan Weinkle
A pair of healers, one an experienced teacher of medicine, the other a freshly-minted intern, reflects on the transforming power of the third year of medical school in the recent piece, “Into the Water – The Clinical Clerkships.”
The intern, Neal Chatterjee, describes the jarring, unnatural moments that punctuated his third year, and concludes that the experience is, “like being thrown head first into water,” only to eventually become such an adept swimmer that one is unaware of the water at all. His teacher, Katherine Treadway, turns this acculturation on its head. During that “power and turmoil,” the “high level of compassion with which students enter medical school” begins its well-documented sharp decline. “It is ironic,” says Treadway, “that precisely when students can finally begin doing the work they . . . came to . . . do . . . they begin to lose empathy.”
It is clear from the examples used by Chatterjee that when Treadway speaks of “power and turmoil,” she means death, or at least catastrophic loss. Idealistic students are face-to-face, in many cases for the first time, with the ugliness of life, and with life’s inevitable end, and they are unprepared. The curriculum does not leave much room for comprehending these experiences; the unwritten curriculum penalizes those who linger too long over them. As a result, they become part of the water, barely even noticed after a time.
Treadway rejects the question, “Can you teach students to care?” in favor of asking how students who enter school caring can be taught how to care. For me, the question is: why do people who clearly have the capacity for empathy lose it along the way?
It is a given for every rising third-year medical student that the “wards” will be hard. There is a proliferation of books: First Aid, Surviving this, Crushing that, Mastering the other. In every case, the mastery and domination is over impossible amounts of knowledge. The “water” Chatterjee referred to, it turns out, is cold.
These Darwinian survival guides do not talk about empathy. Where empathy appears in the first two years of the curriculum it is in controlled settings in which students hear heart-wrenching stories of illness, loss, and death, without any personal responsibility for the people telling those stories. When they rise to third year, few of them have ever heard a resident say, “Watch out for the internal medicine wards; make sure you know how to listen empathetically before you start service.” Yet this is the coldest water of all.
Empathy is hard. It requires an acknowledgement of weakness, of the persistence of loss, and of the incompleteness of success. It requires a shouldering of responsibility for suffering, occasionally alone, because the student is the one the patient talks to and trusts with her story. The student may not be allowed to order a Tylenol without supervision, but she bears the burden of this patient’s suffering. She has had pharmacology, but never been taught to hold a hand or gather the pieces of a shattered dream.
Nowhere is empathy harder than with the dying patient; if empathy requires acknowledging weakness, dying requires acknowledging out-and-out failure. Every time rounds detour around the room of a dying patient or employ appalling terms which I won’t repeat for patients approaching death, empathy is lost. Yet there is no pocket paperback entitled, “Mastering Empathy for the Wards,” or, “First Aid for the Clinical Clerk whose Patient is Dying of ALS.”
It’s time for such a book. It’s time to bring every student face-to-face with loss, outside the comfortable chairs of the small group rooms, whether it’s in Haiti, a heroin-addled small town, or at the bedside of a hospice patient, give them a chance to carry the burden a bit, and teach them how to do it better, longer and stronger, before it all falls on them at once.
Treadway K and Chatterjee N. “Into the Water – The Clinical Clerkships.” N Engl J Med. 364;13: 1190-93. Such a book exists; see our resources section for Mastering Communication with Seriously Ill Patients, by Arnold, Back and Tulsky. We would be proud to see schools of medicine, nursing, rehabilitation sciences, and others take this volume into their curricula.