In the first chapter of his landmark work, Medical Ethics, Thomas Percival calls on physicians to ‘‘unite tenderness with steadiness’’ in their care of patients.
Percival wrote those words in 1803. Today, they sum up what healthcare reform is asking of 21st century physicians: “Patient-centered medicine” requires that a doctor combine strength with compassion. A physician needs courage, fortitude—and great empathy. But, as I suggest in the post below, the hazing that turns medical education into an endurance test does not encourage tenderness. Teaching through humiliation and intimidation only conditions doctors-in-training to develop a “tough hide” as they learn to take abuse without showing emotion.
This is a process that trains young physicians to bury their feelings argue Jack Coulehan, M.D. and Peter C. Williams, Ph.D. in “Vanquishing Virtue,” a superb analysis of the “Impact of Medical Education” published in the journal, Academic Medicine, in 2001.
“The hot-house atmosphere is psychologically and spiritually brutal,” they write, and too often, “students receive little emotional support from faculty” or “role-model physicians.” Instead, students report feelings of paranoia: “I’m always being watched.”
Coulehan and Williams stress that some students survive, spiritually intact: “Certain personal characteristics of the student such as gender, belief system,” and age probably play roles, helping some students escape the most harmful effect of the conditioning. Medical schools that support “family medicine” and offer courses in “communication skills medical ethics, humanities, and social issues in medicine” can help.
Nevertheless, in many instances, a poisonous, punitive culture saps the spirit of young doctors as they learn to “shut down” emotionally.
Little wonder that medical students who have endured this rite of passage resent the idea that nurse practitioners can do the work they do, and should receive equal pay and equal respect when providing the same services. These physicians object, because they feel they have paid very high “dues” to earn the title “Doctor. “
“Physicians have every right to believe that the social utility of their work demands respect, Coulehan and Williams acknowledge.
“However, the duration, rigor, intensity, and abusiveness of today’s medical education also engenders a sense of entitlement to high income, prestige, and social power.” In essence many believe (rightly), that they paid a high price to earn that MD after their name—not just in the form of high tuition ,but in the form of “long hours, deferred gratification, great responsibility–—which then warrant very high benefits in return, the cultural equivalent of ‘‘MD’’ license plates.
This leads to that sense of entitlement,” a belief “that physicians are due a special status in the world of healthcare not just because they have worked so hard, but because they have been so abused.”
While their grievance is justified, a sense of having been abused it is not a strong foundation for self-respect. Nor is it is a good reason to resent NPs. Rather, young physicians should resent a system designed to bully rather than to nurture, and vow not to repeat the ritual when they train doctors.
The Explicit Curriculum vs. The Hidden Curriculum
Coulehan and Williams explore the tension between the explicit curriculum of medical school, and a hidden curriculum, the unwritten code that shapes the values and behaviors of many physicians. “The explicit curriculum stresses empathy and associated listening and responding skills, the relief of suffering, the importance of trust and fidelity, and a primary focus on the patient’s best interest.”
By contrast, the implict curriculum, what they call “tacit learning,” stresses “detachment, wariness, and distrust of emotions, patients, insurance companies, administrators, and the state.” This is how residents learn to survive.