““The vast majority of first-year medical students enter as very caring and compassionate young people,” said Treadway. “Unfortunately, that is a skill that seems to erode…We often fail to live up to our own ideals, not because we choose to, but because we stopped paying attention. Somewhere in the process of training…we forget about the patient, and then we lose a large part of why we became doctors in the first place.”
Treadway said the physician’s time-honored functions—attentiveness, presence, caring and comfort—remain essential, but that “in reality, many patients don’t experience this. We are so busy providing safe, complex care” that the patient’s feelings become inconsequential.
For at least a century, Treadway argued, medical education has been permeated by the notion that deepening scientific sophistication cannot coexist with a sense of caring. Far from a bad thing, medicine’s tendency to become “too scientific,” she said, “reflects an appropriate rejection of old ways of practicing medicine. But have we discarded too much of the old?”
Unconscious acceptance of the “knowledge vs. caring dichotomy sends two really pernicious messages,” Treadway warned: “You can’t be both caring and smart, and caring is not important. There shouldn’t be a choice; patients need both.”
Treadway called being a patient “an extraordinary act of trust and faith. Patients are submitting themselves to us and they need to feel safe in our gaze. We must not forget how vulnerable they are.”
She told of a 25-year veteran physician who, finding himself in an intensive care unit, discovered two surprises. First, every interaction with the multitude of caregivers he encountered daily “was as if each person had a neon sign on their head—‘Care’ or ‘Don’t Care.’ And the second was how important it was that they cared.
“Caring has an impact on medical outcome,” Treadway said. Several studies, she continued, have linked patient perceptions to improved test results.
“What happens to caring?” she asked rhetorically. “Medical education happens.”
In its current incarnation, medical training leaves students “ill-prepared to treat the person who has the illness, but well-prepared to treat the disease,” said Treadway. She cites a sin of omission—what is left out of training—as the culprit.
Medical students have little patient contact during their first 2 years, she explained. “The focus is inward…patients themselves are in some way irrelevant.” But during the third year of clerkships, “demands on students increase dramatically” as they begin seeing patients.
“The third year is full of powerful and potentially overwhelming experiences,” Treadway said. One of her students described it as “a maelstrom of existential quandary.” But ironically, just as patient care begins in earnest, many students experience a significant decline in empathy.
“There is enormous emotional content in medicine, both for us [as physicians] and for patients,” said Treadway, but that freight is rarely dealt with forthrightly. “Implicit in our silence,” she said, “is that feelings are not important” and so trainees bear their confusion, panic and powerlessness alone.
“Students are vulnerable to the messages our silence can convey,” said Treadway. “There is a ‘hidden curriculum’ that is taught by behavior,
not by words.” She called on educators to acknowledge emotionally challenging events as they take place.
“We are thrust into a world most people try to avoid,” she continued. “We have to learn some detachment or else we could be paralyzed. But not at the expense of emotional disconnection.”
Treadway said the consequences of ignoring this aspect of medical training can be stark: “I hate the person I’m becoming,” wrote one student.
|“There is enormous emotional content in medicine, both for us [as physicians] and for patients,” said Treadway, but that freight is rarely dealt with forthrightly.
Trainees need the guidance of experienced mentors, Treadway said. Among their lessons? “It can be rewarding to be a comforting presence, even when nothing can be done,” she said. “Listening brings comfort. But we are largely silent just when patients need us the most.”
Treadway has diagnosed in most medical education a pernicious spiral: students learn to be afraid of their own feelings, then those of their patients, then they suppress their emotions and end up feeling detached.
“Our silence…not only doesn’t nourish compassion,” Treadway said, “but also negates it…we unintentionally, and by neglect, teach [students] not to care.”
She believes compassion is a skill that can be taught. It involves self-reflection, a safe space to explore feelings (even negative ones), an ability to put one’s feelings aside and focus on those of the patient and an ability to appreciate “the power of presence.
“Students need to learn to get the self out of the way, to give up their own agenda so they can really be there for the patient,” she said.
Treadway says real-time compassion lessons “need to be integrated into the curriculum early—we have not done this yet.” She recommends pairing students with experienced practitioners. “It can’t be done by courses on humanism,” she said.
“The extraordinary thing about medicine is that it is an endeavor of the mind and the heart,” she concluded. “We play a unique and powerful role, one that can nourish our own hearts…We need to make [compassion] a more explicit part of the curriculum. It can’t be left to chance.”
The Power of Presence
One of the most important lessons of her own medical training occurred when Dr. Katharine Treadway was paired with an intern who was already seeing patients. The two were at dinner one evening, their duties finished, when the intern decided to look in on a 7-year-old girl with a Wilms tumor.
The child was in the late stages of disease and it was clear that she would not survive, Treadway recalls. Still, the intern summoned the courage to enter the room, where the patient’s parents and both sets of grandparents sat vigil.
The intern simply walked over and wordlessly embraced the parents.
“I learned an important lesson that night,” said Treadway, who doesn’t even recall the intern’s name. “Even when there’s nothing more you can do, you can bear witness to the pain in the room. Doctors can have a profound impact with their kindness and compassion.”
Treadway’s entire presentation is available at http://videocast.nih.gov/summary.asp?Live=10628.