Physicians' feelings: toward a balance in medical education

Imagine you are assisting during an operation. The surgeon is having difficulty tying off a bleeding artery. His brow is sweating and hands are taut as he requests a clamp. The surgeon is handed an incorrect instrument and flings it across the floor, demanding the correct tool. The scrub tech explains that the desired clamp is not sterile. The surgeon yells and throws the instrument tray on the floor. The operating room becomes completely silent. The surgeon regains control, mutters a slight apology, asks for any sterile clamp, and proceeds. He is known as a caring physician, and discussion about his temper never ensues. His behavior remains accepted. Now imagine you are a medical student participating in a surgical case where resuscitation efforts, including cracking open the patient's chest, fail. As the surgical team leaves, the attending physician instructs 2 medical students to practice suturing by repairing the man's chest for his family. Everyone exits, leaving the students to their task without further discussion. The students cope through irreverent humor and forever share a bond created through this awkward moment. Next imagine you are a medical intern on call at an understaffed hospital. The patients are extremely sick, and getting orders completed is difficult. Critical laboratory tests are often reported a day late. Patients die daily. Many patients have terminal diseases, are in great pain, or are severely demented. Conversation in the team room mirrors that in a locker room—filled with derogatory cracks about patients, the system, other house staff, and consultants. This humor, plus a lot of caffeine, helps the team make it through the night. Each of these stories is true. The first happened 13 years ago, and the other 2 occurred this past year. Emotions in medicine are challenging and frequently ignored. Do you remember a colleague in training or practice who attempted suicide, drank too much, or abused drugs? Are we trained to help our colleagues or ourselves? Medicine is rife with emotions, including joy, sorrow, hope, and angst. To promote both personal and professional well-being, we need to address the emotional experiences of physicians. Academic medical centers can help by heeding the following principals: To create humane physicians, we must treat trainees humanely Edmund Pellegrino in 1974 put it succinctly: a humanist physician is the product of humanistic training.1 Yet, medical training today is far from this ideal, and evidence exists that it often is outright abusive.2-5 Reforms must encourage students to talk about their abusive or stressful experiences. Support groups and retreats are one forum for discussing these events.6-9 Alternative techniques such as yoga and meditation offer relief from certain stresses.10,11 Some hospitals support their house staff by limiting work hours and patient loads.12 One medical residency program in Rochester, NY, implemented comprehensive reforms to support humanistic values.13 These focused on respect and shared vulnerabilities by having faculty model these behaviors. They also promoted time for reflection and relationships with mentors. The process toward humane training has begun but needs further refinement and expansion to reach more trainees. The teacher-learner relationship and the doctor-patient relationship are parallel processes The concept that the teacher-learner relationship reflects what occurs between physicians and patients is not new.14 Both relationships involve members with unequal knowledge and power. Teachers and physicians have specific knowledge to impart. Teachers have power over evaluations and early career paths of learners. Physicians have power over patients through the distribution of medications, technologic interventions, and access to consultants. These unequal dynamics leave learners and patients vulnerable and even fearful. Both relationships work best when there is mutual respect, good communication, and agenda setting. The beauty of the parallel process in medical education is that if the teacher-learner relationship is built on positive traits, the learners can apply these skills as physicians with their patients. Markakis et al described a study in which second-year medical students who felt supported by their teachers scored higher on humanistic test scores and assessment of patient-centered interviewing skills than fellow second-year students who felt controlled by their teacher. They concluded that “students who had their psychological needs for learning met were in turn more supportive of their patient's psychological needs.”13 This study supports investing in the teacher-learner relationship to enhance patient care. Medical trainees can develop skills in self-awareness through reflection Although self-awareness by its nature is individualistic, it can be promoted through curricular interventions and group processes.15,16 Practitioners who are aware of how their actions affect patients, staff, and colleagues can help make health care more effective. There must be times during the fast pace of learning the art and science of medicine and delivering care when trainees can slow down to address their inner thoughts and feelings. Energy invested in these 3 educational concepts can help physicians strive toward emotionally balanced careers. Addressing physicians' feelings early on in training may improve rates of career and patient satisfaction and decrease rates of physician impairment and malpractice claims. It is hoped that curriculum reforms in the 21st century will rise to meet this challenge.