There is much talk about cynicism in medicine, and I remember being confronted by it almost from the beginning. In fact, I still remember how shocked I was the first time I heard a provider describe a patient in a disparaging matter.
We were responding to a 911 call regarding a woman in her 30s who was feeling short of breath. I remember being worried; she seemed too young to be a patient. When I asked some of the senior providers why they thought such a young person would feel so short of breath, one of them predicted that the patient would be “a cow.” This provider suggested that she had probably simply overexerted herself and due to her weight this had caused her feel short of breath.
I was astounded at the brusqueness of the comment. I am sad to say, it is not the only time that I have heard similarly callous comments. But the others don’t stick with me the way that first comment did.
And that scares me. Am I slowly becoming the health care provider that speaks poorly of patients? Will a future doctor one day tell a story about something I said about a patient? No health care provider starts their career wanting to become cynical, and yet too many end up that way. Why is that?
The role of residency
Much has been written about the role that our formative years in residency play in the development of cynicism. This time-intensive part of our careers certainly does not create a nurturing environment where we can be our best selves. But I think beyond the time stressors, the distribution of time we spend in the outpatient vs inpatient setting also contributes.
The vast majority of residency training is spent in the inpatient setting. Even though I am in a primary care-focused training program, I will easily spend more than half my time on the wards or intensive care units. While this is not a bad thing in and of itself, I believe it makes it harder for us to maintain compassion.
Hospitalized vs. ambulatory patients
As residents (and even as medical students), we spend much less time in clinics than on inpatient rotations. Thus our first daily exposure to patients — a time when we develop our habits and perspectives about patient care — is our exposure to patients in the inpatient setting, when they are at their worst. Unfortunately, just like I am not my best self in a stressful, overworked setting, I imagine most patients are not their best selves in the hospital either.
It’s important that we remember this. We rarely see patients at their best times. When people are healthiest and happiest, they often do not come to see us. If they do come in, it will be into our clinics.
Even in our clinic, unless we go out of our way to ask, we never get a full sense of who a patient is. Instead, for many patients, we see only the flaws that resulted in their hospital admission and their response to a stressful situation. If we’re lucky, we get glimpses of the joy they bring into the lives of others; but oftentimes, we never get the privilege of seeing the virtue of each patient.
The value of continuity clinics
Despite my clear biases — I chose to join a primary care-focused residency program — I believe the value of continuity clinics cannot be understated for all physicians. No young physician wants to be jaded or callous and yet we are often placed into circumstances where that is the easiest path to follow. When we see patients only at their worst, it is hard for our perspective not to be skewed.
This is why I intend to hold on so tightly to my clinic experiences. They give me a chance to see my patients (and hopefully all patients) in a better light. When we get to know our patients as people rather than diseases, we at least have a fighting chance at remaining compassionate.
Elaine Khoong is an internal medicine resident. This article originally appeared in The American Resident Project.
