Sunday, September 19, 2010

How to Learn "Fake It Till You Make It" Compassion

The Wall Street Journal has a new piece in their Taste column, "Physician, Humanize Thyself", about the proliferation of White Coat ceremonies at medical students, and whether they instill a greater level of compassion for students as they advance in medicine. The ritual was started a few decades ago, when students were noted to have less idealism and more cynicism than their predecessors, who had since traversed through the medical malpractice and billing changes. The idea was to make them more aware of the figure at the center of the medical world, the patient, and to retain that essential sense of compassion. Another figure in the article questions how effective this ritual can be, since the white coat is intended to visually set the doctor apart from other figures in the hospital setting, not to make the patient feel as if the doctor is on his or her side. Other techniques used by medical students often involve rituals for the cadavers, such as an appreciation ceremony where letters and poems are read aloud to the brave donors. The article misses the point, however, about what real compassion is and how it is manifested. When I applied for medical school, the two themes which pervade the interview are those of compassion and thirst for medical knowledge. But the reality is that almost no medical student truly understands compassion in a specific medical sense (unless they were previously a medical worker in some other capacity).

Compassion, when you are well rested and well fed, relaxed and without pressure, is fairly easy for most people. It is easy to walk into a patient's room at 9 am, and say that you are sorry for their problematic situation, and here is what we are planning to do, and do you have questions? Great! Thanks. Anybody who is a decent human being can do that. But real compassion is an acquired skill. It is the ability to care when you are so tired that you just do not care about anything else except sleep. It is the ability to care that someone is in pain, even if they have a long history of causing the same self-trauma over years. It is the ability to thoroughly describe a medical problem in layman's terms when you have no time to spare, and not lose patience when the patient still did not understand. It is the ability to understand that taking care of someone might require you to cause them some pain or discomfort in the short-term sense, and still be able to do it anyways without hesitating. These are all things that you just cannot pass on in a white coat ceremony, or any other ceremony. Like so many of the real skills in medicine, you have to work them, one 24-hour shift at a time. And until you have those skills mastered, you have to pretend you have them already, lest you cause major damage to the patient and family. In other words, to become a truly compassionate doctor, sometimes you have to fake it until you make it.

It sure would be nice to be able to help medical students with the faking part, at least. My medical school did one thing that I appreciated, which was practicing patient encounters with actors. Many times our experiences were laughable, and taking them seriously was next to impossible. Specifically, I remember an encounter where I had to tell a "wife" that her husband had died from a heart attack. Her response was to repeat "I can't deal with this right now, I need to get the groceries and pick up the kids" ad nausem, and then eventually stop talking. I had to bite my lip to keep from laughing, because it all felt so fake to me. (I had been expecting to see her cry, or yell at me, or have some kind of response which actually related to the news.) But having now spoken to several families after patients pass away, or are about to, I see that that experience was actually helpful in preparing me for the variety of ways that humans can respond to news. More important than the formality of a ceremony for medical schools would be the investment in standardized patient encounters, and education in situation-appropriate language. This is an area where most students (and many doctors) are still painfully lacking. At least if we have to fake compassion, we can do it with sensitive language and formalized demonstration of respect.


  1. I recently had an experience like this, with actors. Our scenario was that the patient had just been told they had cancer, but no information about the prognosis ('lymphoma' is a very broad diagnosis!). I was a bit taken aback at some of the students' reactions - but hopefully they'll have some more time to practice it before they have to deal with it with real patients - but you can never tell when that situation will arise. For me, it was less than two months into medical school.

    Interestingly, we don't wear white coats here anymore. I'm disappointed, mostly because all that pocket space would be really helpful!

  2. don't be disappointed about the white coats, I've long felt that they are a hassle and we need to be rid of them. The fact is, nobody ever washes them, you get dirty germs and blood all over them, the stains never wash out, they're heavy and obnoxious. From an ID standpoint, we really should straight up ban all white coats, long-sleeved shirts, ties and just wear color-coded scrubs, a fresh set every day.

    I know regular scrubs don't have many pockets, but I did buy some at Wal-Mart the other day which have 3 pockets on the top (and none over the breast, even better), and the pants have 3 as well, cargo style. It's so much more useful of a design.