The following is the script of a talk
that I gave last night at the induction ceremony for the Florida International University Herbert
Wertheim College of Medicine’s 2014 Gold Humanism Honor Society.
Thank you so much for the
opportunity to speak to you this evening.
The Gold Foundation was formed in 1988 with the purpose of
nurturing and preserving the tradition of the caring physician. There was a
concern then (as there is now) that the outcome of our medical education
process was doctors who no longer had compassion for patients. The patients
that were, for the most part, the very reason that we went into medicine in the first place.
The Gold Foundation proposed that
the humanistic doctor, not just has, but displays on a daily basis certain
attributes, described as IE CARES:
Integrity – the congruence
between expressed values and behaviors
Excellence in clinical care
Compassion – awareness of
the suffering of others but also working to relieve it
Altruism – the capacity to
put the needs of another before your own
Respect – regard for the
autonomy and values of another
Empathy – the ability to put
oneself in another’s situation
Service – sharing with those
in need
These core attributes have real
value and meaning in the care that we provide to our patients on a daily basis.
When the Gold Foundation was
first formed, they asked several important questions.
1.
Can we
identify students who are both scientifically proficient and compassionate?
2.
Are we
selecting idealistic and humanistic young people for medical school, but then discouraging
their spirit of caring through the education process?
3.
If we
select students who don’t have the right characteristics, can we through
education, teach them to be?
I would like to spend the next
few minutes talking about each of these questions. As I speak, I believe that you
will see the relevance of the Community Capstone project to this discussion.
So, the first question was:
Can we identify students who are both
scientifically proficient and compassionate?
Before we answer that question,
you need to ask yourself an important question: do you believe that it is
important to be both scientifically proficient and compassionate?
Patients definitely do. A Health
magazine survey (1) a few years ago found that the number one thing that
patients wanted was a doctor who listens to them. Number two was being up to
date on the most recent information in the medical field. Did you hear that? A
doctor who listens was first, then being up to date.
Patients don’t want to see a
really smart doctor who is a jerk
But they also don’t want a caring
doctor who doesn’t know anything.
Both attributes are important.
In February of last year, the Association of American Medical Colleges’ (AAMC) Committee on
Admissions endorsed a list of nine core personal competencies that medical
students should have prior to beginning medical school.(2) These included ethical
responsibility, dependability, a service orientation, social skills, the capacity
for improvement, resilience, cultural competence, oral communication and
teamwork. These seem like important
characteristics that have some commonalities with the Gold characteristics even
though it does not specifically mention compassion.
A survey of medical school deans
done in 2007 (3) found that 90 percent thought that “Caring Attitudes” were
emphasized during the pre-clinical and clinical years. 93 percent of the
schools asked admission interviewers to assess the caring attitudes of their
applicants. But do they do that?
I am sure that you remember the application
process to come to medical school here at FIU. We started out looking at your
college grades and your MCAT scores. Every school does that. Most every school in the country also
uses an in-person interview to determine if you get into medical school. The interview’s purpose is try to figure out
what kind of person you are. Do you have those other characteristics that will
make you a caring and compassionate physician?
A specific type of interview,
known as a semi-structured interview, is actually pretty good at predicting performance in medical school. And importantly, is better and figuring
out if an applicant has those important personal characteristics such as
compassion and ethical attitudes.(4)
So, the answer to the first question
is yes, we can identify students who are scientifically proficient and
compassionate.
The second question was:
Are we selecting idealistic and humanistic
young people for medical school, but then discouraging their spirit of caring
through the education process?
To answer this question, I want
to tell you a true story that took place 23 years ago.This story is from my medical school experience.
My first rotation was surgery. I
was assigned to the VA hospital. It was across the street from the medical
school and everyone wanted to go there. Remember, this was back in the old
days. We never saw a faculty physician! So as a student you actually got to do
a lot while you were working with the residents.
The surgical residents ran
everything. And the Chief Residents were like gods. They could do anything,
they knew everything, and could handle any problem that came along. We had one
surgical chief that everyone was terrified of: Dr. X *. And as luck would have it, I was assigned to his team. The Red
surgery team. I have no idea where he is now but back then he was the Chief
Resident and ran the entire surgical floor.
Every morning we arrived at about
4:30 to pre-round on our patients. Each student carried five or six patients
and we had to present each of them on rounds. At six o’clock AM, we met with
the junior residents and went over all of the patients, updating them on any
issues from the night before. We went to surgery in the morning and surgical
clinic in the OPD in the afternoon. And
then we would wait. We had to wait for Dr. X to finish his case or clinic or
his coffee (whatever he was doing) so that we could round again with him.
When he was ready, we would get a
page. Back then it was just a voice page (there was no such thing as cell
phones or text messaging). The page said “RED DOGS to the ICU, RED DOGS to the
ICU”. We were the dogs, the medical students. At this point, it was usually 7
or 8 at night and you had been in the hospital since 4:30 or so.
Rounds with Dr. X were an
exercise in terror. If you talked to
long, he would tell you to shut up. If he asked you a question and you got the
answer wrong, he would just shake his head and say, “Stupid Medical Student”.
If you tried to talk about family history or what the patient’s spouse was
worried about or gave any social history he would cut you off. “I’m not
interested in that…”
Was that discouraging? Yes it was.
Experiences like this can cause
you to develop a hard external shell. It is like a callous that develops on
your psyche, to keep you from getting harmed. A survey of medical students found
that they identified empathy, communication, integrity, and honesty as the most
important qualities of a doctor.(5) But Morley and colleagues at SUNY
Upstate in Syracuse New York found that idealism begins to decline as early as
the end of the first year of medical school. (6) Empathy begins to decline as soon
as you start to see patients and declines across all of the years of medical
school.(7) You start out as caring people and then the weight of the medical
education system begins to wear you down.
So the answer to the second
question, is yes. We do things during the educational process that can damage
you.
The third question was:
If students lose (or never really had
important characteristics) can we through education, help them to develop or
learn them?
From my perspective, this gets to
the heart of the issue.
This is the intersection of the
Gold Humanism Honor Society and the Green Family Foundation NeighborhoodHELPprogram.
If you want students to learn to
be caring and compassionate physicians, it is important to see patients in the
communities where they live. As a
student it is easy to get jaded by the difficulties of the patients around you.
Why did that
patient miss his appointment?
Why doesn’t she
get out of her house and walk more?
Why don’t they
eat more healthy foods?
People smoke. People drink. People
are obese, they don’t exercise, they don’t eat right. They don’t take their
medicine. It is easy to get to the point where we believe that every medical
problem that our patients have is their own fault. Rather than seeing and
understanding that people’s lives are complicated and difficult. More difficult
than our lives. Far more difficult than my life.
The only way to see that is to go
out into the community. Get to know
patients in their own world, not in the artificial world of the clinic or the
hospital. But in their home.
That is the simple brilliance of
the NeighborhoodHELP program. You have the opportunity to see patients and
families in their own home. Where they live. In their neighborhood. Their
community.
The Community Capstone projects,
build on that experience. The best Capstone projects, such as some of these
that are honored here tonight, are the ones in which a student or group of
students was impacted by something that they saw in the community, an issue.
They found a community partner who was also interested in that issue. And they
worked to address the issue.
We know that the humanistic
qualities that are held up by the Gold Foundation can be nurtured through
exposure to mentors who also have those qualities. Through experiences that
encourage you to care for people not just take care of them. And through
opportunities to reflect on those experiences.
When you applied for
medical school, all of you said something about how you wanted to help people.
You wrote in your personal essays about your motivations for going into
medicine. I have read thousands of those essays over the years. Everyone says
that right things, but many don’t follow through on those words.
You have the opportunity to do
something different.
To care for people
To make a difference in their
lives
Congratulations and thank you
again for the opportunity to talk to you today
References
(2) Koenig TW, et al. Core
Personal Competencies Important to Entering Students’ Success in Medical
School: What are they and how could they be assessed early in the Admission
process? Acad Med 2013; 88(5): 603-613.
(2) Lown BA, et al. Caring attitudes
in medical education: perceptions of deans and curriculum leaders. J Gen Intern
Med 2007; 22(11):1514-1522.
(4) Pau A, et al. The Multiple Mini-Interview (MMI) for student
selection in health professions training - a systematic review. Med Teach. 2013;
35(12): 1027-41.
(5) Hurwitz S, et al. The
desirable qualities of future doctors—a study of medical student
perceptions. Med Teach 2013; 35(7): 1332-1339.
(6) Morley CP, et al. Decline of
medical student idealism in the first and second year of medical school: a
survey of pre-clinical medical students at one institution. Med Educ
Online 2013; 18.
(7) Neumann M, et al. Empathy
decline and its reasons: a systematic review of studies with medical students
and residents. Acad Med. 2011; 86(8): 996-1009.
* (name removed to protect his identity)
