Medical Schools Discover Value in Dispensing Compassion

he late dean of the Harvard Medical School, Robert Ebert, delighted in
telling applicants that a would-be student should be first in his or her
class, a concert violinist without an ego, an Olympic skating champion who
has climbed Mount Everest and has lived in a tree hut in the Amazon, and a
relative of Mother Teresa.

Putting it less facetiously in letters to elementary schoolchildren who had
written asking what they had to do to get in, Dr. Gerald Foster, a dean of
admissions, advised, "You should be a good student, but it's also important
that you be a good person, helpful to your parents and to your classmates,
because these are the things we look for in people who apply."

Implicit in the two educators' remarks is respect for a quality that some
fear is perilously close to extinction: compassion.

Once the hallmark of the buggy-riding, house-calling, bedside-sitting,
fee-waiving family doctor of yesteryear, the ability and the willingness to
feel another's pain often seems a poor substitute for skilled robo-surgical
hands and dazzling diagnostic electronics.

Whether it is out of guilt, the need to shape an institution's public
relations image, health care consumer protests, or some Hippocratic
epiphany, compassion has become medically and politically correct.

Re-emerging increasingly among educators, medical associations and hospital
administrators, it is as though medical professionals and their patients
have suddenly discovered humility, mortality and goodness, and given the
boot -- at least on the surface -- to the God-like physician whose idea of
a doctor-patient relationship is looking down at a groggy patient and
saying, "Do you see these hands, Madame? They saved your life!"

Consider these recent examples:

•At Yale, deans of medical departments put white coats, known as "cloaks of
compassion," on each newly enrolled student. During the ceremony, the
students also recite a "Human Relations Code of Conduct."

•At the University of Texas Medical Branch, medical school graduates who
embody the ultimate in patient care are nominated to receive the
Gold-Headed Cane Award because of their "interest in the welfare of patients."

•At the University of New Mexico, second-year medical students on pediatric
rotation learn how to deliver "bad news" from a panel of parents.

•At the Medical University of South Carolina College of Medicine, students
participate in interactive seminars on faith, mindfulness, forgiveness,
guilt, shame, prayer, tragedy and the power and limitations of the healer.

•At the Pennsylvania State University College of Medicine, some fourth-year
students take an elective course that includes a daily spiritual log, a
personal spiritual profile and a case report of a patient who has used
religion as a means of addressing a medical problem.

•At University of Kansas, the medical students learn "cultural competency,"
participating in overseas programs to help them develop cross-cultural
awareness and capabilities.

•At Harvard, first-year students are assigned patients with a
life-threatening illnesses, and the students are expected to develop
ongoing relationships with the patients and their family members through
multiple visits.

Elsewhere, medical students study family dynamics and domestic violence,
take to hospital beds and play at being patients themselves, smear their
eyeglasses with vaseline to appreciate what it feels like to have
cataracts, and interview "standardized patients" -- real or simulated
patients who have been carefully coached to present their feigned illnesses
in a standardized form.

The goal is communication, the keystone of the doctor-patient relationship.

Without a doubt, for many patients, the worth of their doctors has more to
do with their ability to listen than with where they went to medical school
or how many years they have been in practice.

Indeed, a national survey conducted in 1999 for the Association of American
Medical Colleges found that only 27 percent of patients cited prestigious
medical schools as a factor in choosing doctors, while 85 percent
attributed their choices to the doctors' communication skills and caring
attitude, and 77 percent cited the ability to explain complicated medical
procedures.

It was a wake-up call for the nation's physicians. As Dr. Nancy Angoff,
associate dean of student affairs at Yale Medical School, tells her
incoming students, "None of us here has any doubt that you will be able to
speak the speak. What we don't want to happen is for you to forget the
human element, the patient's story."

But can compassion be taught in medical school?

"You have to start with students who show signs of caring at the very
beginning and who value it," Dr. Angoff said. "It also needs to be valued
by the institution. It needs to come from the top."

Moreover, embedding compassion in every aspect of the curriculum is not
easily accomplished. Often, it is emphasized only if the basic science
faculty does not have to give anything up.

Moreover, good role models, vital in the making of good doctors, do not
grow on every ward, and students are still rewarded for their skill in
recalling minutiae.

Students also find all too quickly that many hospitals are so high-tech
that hands-on care often means hands on a hand-held computer that registers
symptoms, diagnoses and treatment options, and that the hospital
environment can sometimes even be indifferent to a student's presence.

What does seem to be effective, however, is for students to be on intimate
terms with patients from the very beginning of their training, continuing
the relationship through the third and fourth years when they are apt to be
less under the control of the medical school and more under the sway of
their hospitals.

At Harvard, if a patient dies during the elective course that pairs
students with dying patients, the students are encouraged to attend the
wake and funeral and to share in the family's grief.

"Learning to grieve," says Dr. Susan Block, an associate professor of
psychiatry at Harvard, "is also part of being a doctor." But will new
doctors hold on to ideal values once they are out practicing in the real
world?

Even when they want to, the system seems to conspire against it. Hospitals
are committed to the concept of the "rapid-through-put-patient" -- get them
in, get them fixed, get them out.

Personal history-taking that used to take 30 to 45 minutes now often takes
just 5 to 15.

Doctors are pressured to see more patients in a shorter period of time and
to focus on the ailment, not on any behavioral elements that might "intrude."

What effect the current emphasis on compassion will have on future
generations of doctors remains to be seen.

On one hand, there will always be doctors who heed the bit of verse about
the Victorian physician:

He asked no social questions, He probed no hidden shame; He only spoke
obstetrics When the little stranger came.

On the other, some medical students, no doubt, will share the sentiment
that one Harvard student wrote recently to her patient:

"Prior to the class, I never was sure about how to talk to anybody about
death. You have given me invaluable gifts of insight. Now when I am caring
for my own patients, especially those who are near the ends of their lives,
you will always be there."


By JOHN LANGONE
Copyright 2000 The New York Times Company
"http://www.nytimes.com/library/national/science/health/082200hth-doctors-co
mpassion.html"

janet paterson
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