I first noticed it while working in the emergency room. I’m sitting at a computer at the nursing station, which is surrounded on all sides by beds with patients in them, chairs with patients in them, patients ambling around aimlessly in gowns, bored, frustrated, tired. The bank of computers at the nursing station is like a fortress, separating providers from the throngs of sick by means of a chest-high wall. A patient walks over. Standing directly in front of me but addressing nobody in particular, she asks for one of the many things patients ask for: something for pain, something for sleep, a sandwich, their doctor. I forget what it was because in that moment, although I hear her, I pretend not to. I don’t answer. I try to look busy. My eyes stay resolutely glued to the screen.
That was only my second day in the emergency room as a newly-minted MD. I’m not proud of how I acted, but I know that my reaction to that patient was not unusual. The people seated on either side of me did the same. The way these interactions typically go is that, unless the patient approaches her doctor or nurse specifically, her request will go unanswered for several awkward seconds until some exasperated person, perhaps propelled by a sense of guilt, will come back with a less-than-enthusiastic “Can I help you?”
If empathy is a finite resource, the demands of hospital patients
stretch it quite thin.
This type of behavior is an unfortunate byproduct of the overwhelming patient-to-provider ratio at a large medical center. The prevailing attitude is one of “not my patient, not my problem.” Saddled with an overflowing patient panel and a seemingly endless list of tasks to complete, any additional work, especially for patients who are not your personal responsibility, is carefully avoided. Hence the downcast eyes every time one comes complaining. The trouble with this is it makes you feel like a bad person. If a stranger on the street asks me for directions, I’ll happily oblige. But the hospital is different—that stranger is the 50th person to ask me for something that day, and instead of “directions” the request is “morphine.”
If empathy is a finite resource (and I recognize that for some of the saintly among us it is not), the demands of hospital patients stretch it quite thin, and at the end of the day what little is left is reserved for my patients alone, with none to spare. To those directly under my care, I give the best of myself; to all others, I turn a blind eye and a deaf ear.
Where else is behavior like this acceptable? And why is it acceptable in such a service-oriented field as medicine?
Doctors are, I believe, more empathetic than the average person on the street, but they are not superhuman. Most enter medical school with a great deal of idealism, and they leave more cynical, jaded and disillusioned. Studies that look at this phenomenon attribute it to the stress of medical education and the experience of the clinical years, when students are first exposed to patients and senior role models, both good and bad. All sorts of strategies have been proposed to “teach” empathy, including videotaped patient encounters, workshops focused on developing interpersonal skills, and even limiting medical students’ exposure to “difficult” patients early on. But all of these interventions are aimed at coping with a toxic culture rather than combating the culture itself. Medical students become jaded because they are abused. Interns lose hope because they are drowned in menial tasks. Attendings miss the unique privilege of doctoring because they feel like automatons in the great health care delivery machine. It should come as no surprise that empathy deteriorates and sometimes vanishes during the long and grueling ordeal of medical training. What should surprise us—and this is a testament to the resilience of doctors—is that by the end there is any empathy left at all.