by Andre Alcon, MD
It’s hard to believe we’ve finally reached the end of medical school. Cadaver lab, clinical clerkships, sub-I’s and interviews; each has left its indelible mark. We’ve no doubt morphed into budding clinicians, but how has medical school influenced our sense of identity and perspective? A 2008 study by Newton et. al. found a significant decline in medical student empathy over four years, regardless of gender or specialty, with the most significant reduction occurring after third year clerkships (1). This is only one study, but a quick search of the literature reveals similar themes afflicting medical students and residents alike. Surely people become more cynical with age, but there are undoubtedly elements inherent to our profession that hardens our heart.
Medical student empathy measured over the course of medical school. Adapted from Newton et. al.
I am the first doctor in my family, so when I began medical school, I guess you could say I had a naïve view of the journey ahead. I obviously knew of the formal curriculum- the classes and clinical clerkships-but I had almost no understanding of what has been called the “hidden” curriculum, i.e. the learning that occurs during morning rounds, the power dynamics that exist within the hospital, and the general medical culture that we operate in every day. All of these experiences, most good, but some bad, ultimately alters our view of our patients, our colleagues, our job, and ourselves.
Many medical schools, Yale included, have implemented longitudinal courses in medical ethics and professionalism to help students navigate and interpret this hidden curriculum. These classes, while seemingly exaggerated and at times futile, allow us to at least be more mindful of the profound consequences many of these experiences can have so that we can more effectively cope and incorporate the lessons we learn from them. After four years of medical school, it is safe to say that most of us have encountered tyrannical attendings, power-hungry nurses, or unreasonable patients. There is little we can actually do as medical students to change this, but understanding the situation and coping with it appropriately is crucial to our development into professional and compassionate physicians.
This awareness will be even more important during residency, not only for ourselves, but also for those around us. In a hostile environment where residents slug it out day after day in the hospital with no rest and little appreciation, it is easy to forget who we are and who we used to be. Attending physicians and senior residents often rush to yelling if something isn’t done their way, but rarely take ten seconds out of their morning to say, “thank you for keeping my patient alive last night,” or, “you did a good job.” Since keeping our patients alive IS our job, maybe I am being unreasonable. On the other hand, could it be that this dynamic is just another manifestation of the hidden curriculum we experience every day?
I am not yet a resident, but with all of the things that residents deal with on a daily basis, I can imagine how easily patients can become just another item to scratch off the list, especially when there are fifty other checkboxes on that list. As medical students, we sometimes see residents act this way and, unconsciously or not, many of us incorporate these behaviors into our own. After all, residents and attendings are our role models. Obviously, none of us enter residency with notions like these in mind, but they can and often do develop. Indeed, we will each find our own coping strategies to deal with the stress of residency. This is completely normal and healthy but due to the nature of our job, we must continue to remain mindful of the emotions and attitudes that they can generate.
Adapted from Resident Service Committee, APDIM. Ann Intern Med 1988; 109-154
How then, can we be mindful as residents? I don’t profess to have the answer since I have not even graduated yet. However, I have talked with residents in many different specialties and most of them say the same thing: don’t forget to devote some time to yourself every now and then. It doesn’t have to be trekking through the Himalayas, though that would be nice. Ironically, it is oftentimes the small things that bring the most joy; the nights spent at home cooking a nice meal, talking on the phone with family and friends, or just people watching in the park on a sunny day. Obviously, I won’t be able to do these things every day or every weekend for that matter, but they serve as invaluable reality checks that will help me to be a more efficient and empathetic physician. If anything, it reminds me that most of the patients I help do the exact same things when they’re not sick in the hospital. I would be an incredibly difficult person to get along with if a disease was keeping me from the things I love— just ask my parents. Ultimately, we can’t fully care for our patients if we do not take care of ourselves first. Furthermore, when we take care of ourselves, we can be more mindful of how we treat our patients, our colleagues, and our job.
Whatever method you choose, hold onto it and don’t forget it. A recent survey in JAMA found that roughly 58% of general surgery residents seriously considered quitting during the course of their training (2). I am biased, but I suspect the rate amongst plastic surgery residents is much lower. Regardless, I hope that a sense of mindfulness and perspective during residency will keep me in the other 42%. So, for the next two months before intern year, as I worry about the strength of my clinical skills, I am going to try to gain some perspective while I travel, paint, cook, and spend time with family and friends. I’ll think about how the hidden curriculum has changed me. Moreover, as I stare out at the city of Siena, which is where I write to you now, I’ll think about the type of role model I want to be and how I want to contribute to the hidden curriculum.
The Duomo in Siena, Italy viewed from my apartment balcony…perspective.
1. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Academic medicine : journal of the Association of American Medical Colleges. 2008 Mar;83(3):244-9. PubMed PMID: 18316868.
2. Gifford E, Galante J, Kaji AH, Nguyen V, Nelson MT, Sidwell RA, et al. Factors associated with general surgery residents’ desire to leave residency programs: a multi-institutional study. JAMA surgery. 2014 Sep;149(9):948-53. PubMed PMID: 25075473.