The erosion of compassion in medicine

With my first thrust on his chest, I shattered his sternum, feeling his bones crumble in my hands. His eyes were wide open but lifeless. Dried secretions crusted his lips. His dusky skin tone indicated my efforts would be futile. Nonetheless, I proceeded with cardiopulmonary resuscitation as I was trained to do.

Soon the room was bustling with medical residents and nurses. A controlled chaos ensued. We inserted a breathing tube into his airway. We alternated pounding on his chest 100 times per minute to the beat of “Staying Alive” by the Bee Gees. We drilled into his fibula to gain IV access and pumped him full of epinephrine and saline. After 45 minutes, the 90-year-old man was pronounced dead. The commotion abruptly shifted to an eerie stillness, with alarm bells still chiming in the background. The floor was littered with syringes and streaked with blood.

I returned to my windowless, fluorescent-lit room and plopped in front of the computer to complete the required checklists for the 50 other patients I was responsible for that night. There was no debriefing. No reflection on the loss of a life. No processing of the emotional trauma of a human being dying as I tried to save him. I didn’t even acknowledge it.

I began my decade of medical training as an optimistic, well-intentioned student who wanted to devote his career to service and healing. I came out the other side a cynical physician devoid of compassion for myself and the world around me.

The selection of medical school applicants, the training process itself, and ultimately, the system for delivering health care have eroded compassion and human connection in medicine.

Yet, in the coming age of algorithm-based medicine, rapid technical integration, and artificial intelligence, human connection will be the primary offering of the physician of the future, and compassion will be fundamental to delivering quality care. The future of health care demands a new paradigm for selecting and teaching students and training physicians that instills humanity in medicine.

Many students enter college with the aspiration of applying scientific knowledge to cure disease and ease suffering. However, a C on the first organic chemistry midterm exam quickly ends this dream. In this weeding-out process, the pre-medicine basic science classes discourage countless students from pursuing medicine. They learn that if you cannot recreate the Williamson Ether Synthesis on an exam or achieve a sufficient purified compound yield in the laboratory, medicine is not for you.

As a quintuple board-certified cardiologist, I can confidently say that my organic chemistry knowledge had no bearing on my progression through medical training and is irrelevant to the day-to-day demands of clinical medicine. Too many potentially wonderful physicians are turned away from the field within the first months of college—or later when they become discouraged by the Medical College Admissions Test that rewards fast reading and test-taking skills. The rigid premedical science curriculum squelches creative thinking, crowds out social consciousness, and disproportionately discourages those who are most underrepresented in medicine.

In medical school, classes are then filled with organic chemistry whiz kids, speed readers, and top-notch test-takers. They are thrown into a highly competitive, academic pressure cooker where the top performers are granted access to the specialties with the highest compensation and greatest prestige. A superior medical student can consume and reproduce facts and perform research to generate publications in high-impact journals. This process is not designed to produce conscientious, fastidious, and empathetic physicians. On the contrary, medical school molds future doctors who are focused on personal achievement and notoriety.

The next stages of training—the internship, residency, and fellowship—are the most formative years of professional development, and they define the clinician’s identity. The physician trainee is the primary clinician responsible for patients hospitalized for a vast number of complex medical conditions. The daily patient roster is simply a list of medical conditions, devoid of the human experience connected to them. Bedside rounding and patient interactions are formalities at best, and more often a distraction and nuisance. Daily work involves hours in front of a computer screen, poring through troves of clinical data, with a focus on logistics: following up test results, calling consultants, arranging patient transportation. At least the regimen is a distraction from the ubiquitous pain and suffering. Facing that reality would be debilitating.

The newly credentialed physicians enter a health care environment driven by productivity, efficiency, and procedural intervention. With hospital systems under immense financial pressure, physicians are asked to see more patients in less time. Revenue-generating procedures garner institutional support and recognition. Establishing patient rapport, preventive health interventions, and lifestyle counseling receive far less attention.

Cardiology, my specialty, serves as a clear microcosm of health care’s broader failures. Valve replacements, ablations, and angiograms produce the highest reimbursement, provide content for interesting research, and generate partnerships with industry. Thus, interventional cardiology sits at the head of the table. Meanwhile, preventive cardiology services are inadequately reimbursed and, consequently, generate less interest.

In-depth data analyses have shown that a patient-clinician relationship driven by compassion has a significant and direct effect on health care outcomes. In my field of preventive cardiology, we take a holistic approach to patient care and offer low-risk, high-yield interventions to promote long-term wellness. At the core of this patient-centered clinical approach is a profound connection between the physician and the human being in the exam room.

Compassionate care is built on trust and empathy. It allows for more effective communication of the medical information the patient needs and what the patient should expect. When patients are treated as valued partners in their care and are engaged in shared decision-making, their treatment adherence and outcomes improve. Understanding the patient’s psychosocial environment allows for a more effective and tailored clinical approach.

I remain optimistic that compassion can be reinfused into medicine and that a therapeutic presence can be cultivated in the future generation of doctors. This will require shaking up the current pathway to education, clinical training, and health care delivery.

First, medical schools should refine their admissions criteria to place a greater emphasis on community service, emotional intelligence, and broader life experience. In addition, there must be an overhaul of the pre-med college curriculum. A shift from esoteric basic science coursework to the humanities would help tease out more well-rounded, psychologically minded candidates. The curriculum must incorporate more instruction on motivational interviewing techniques and have students directly work with psychology professionals on a regular basis.

In the crucial and formative clinical years after medical school, trainees would greatly benefit from enhanced psycho-education, mental health resources, and more humane work hours. Medical residents and attendings should receive more robust support from mid-level providers and medical scribes. Such support would offload the burden of medical documentation and allow physicians to leave their computers and spend more time at the bedside.

Finally, health care itself must reward patient-centered care. Physicians who take the time to build rapport and connect with their patients would be compensated similarly to their colleagues who perform invasive procedures. Fortunately, the current/evolving shift from a fee-for-service model to a value-based care system will help realign hospitals’ priorities.

To be sure, some of the leading academic institutions and health care systems have begun to reform the training process and the delivery of care. Mount Sinai’s Icahn School of Medicine offers a non-traditional premedical track that allows college students to major in the humanities and condense the basic science coursework into an eight-week summer program. Johns Hopkins University School of Medicine has integrated resilience training into the medical school curricula. RUSH Medical College, my institution, offers small learning communities, a pass/fail grading system, and a faculty mentorship program to build interpersonal connection and prevent burnout. RUSH offers all its students, trainees, and employees robust mental health services and places a strong emphasis on quality of life.

Hospital systems are adopting time-based physician compensation models, and more institutions are participating in accountable care organizations, valuable strides toward improving the quality of care.

These examples are among the steps that can lead to better health care overall. We must overhaul the current model of medical education and training, and hospital systems need to have the will and the financial resources to fully embrace compassionate, patient-centered care. If the financial vise continues to tighten on hospital systems and bedside medicine fails to keep up with technology, physician compassion will continue to erode, and patients will suffer.

Daniel Luger is a cardiologist.

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