I still think that the third year of medical school serves a wonderful purpose. I never learned more during my entire school experience (perhaps I learned more as an intern, but that is post-graduate).

Danielle Ofri writes through darkened lenses: The Darkest Year of Medical School.

So for the non-physician readers let me give my opinions on the third year of medical school. After two years of mostly classroom experiences, our students learn directly from patients, residents and teaching physicians through participation in patient care. We replace the theory with actual patients.

Students mature dramatically during this year because they are exposed to the broad spectrum of social classes, diseases, prognoses, and outcomes (both good and bad). For most students this is the first time they really witness death. They see the ravages of drug abuse, alcohol abuse, food abuse, firearm violence, unprotected sex and diseases that seemingly randomly occur in patients.

When patients come in with repeated admissions for opioid seeking behavior; when patients come in because they do not take medications that work for their condition; when patients come in because they try to treat HIV with crack cocaine, then students become a bit jaded, or perhaps actually realistic.

Here is the harsh truth. We cannot help everyone. Some patients do not want us to help them. Some patients see us as a gateway to the opioids or benzodiazepines that they seek. Some patients have families that treat them poorly.

Do we really lose empathy? Or do we reserve our empathy for specific situations? George Orwell says, at the end of Animal Farm, “All animals are created equal but some are more equal than others.”

I know no physicians or nurses who treat all patients with the same degree of empathy. We have great empathy for many patients, but some patients just frustrated us. That does not make us cynical. Our growth represents a realistic view of the world.

We really do care much more about some patients than others. We really do want the best for everyone, but focus more energy on some. Does that make us cruel, jaded or bitter? I really do not think so.

I have worked with students and residents for 35 years. They are great people who have to deal with death, morbidity, verbal abuse, and sometimes an inability of the patient to help themselves. They therefore adjust how they work with patients based on how the patient acts. They have plenty of empathy when the patient can accept it.

We should not over-analyze the studies claiming loss of empathy. We should work with students and residents to teach them respect for all patients, but allow them to treat each patient individually. We must set good role models. But we should not get over concerned about the changes the third year students undergo.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.