Compassion, callousness and medicine

Pre-Med & Medical School Pre-Med Topics
1

<p>Heard from D2 today and her experiences in Africa are seriously discouraging her from medicine.</p>

<p>D2 has a tender heart and is a very compassionate person. She's also an idealist. She has been medical volunteering since the summer after 7th grade and has never wavered from her desire to be physician. Until now. </p>

<p>Today she assisted in debriding a burn victim. (BTW, the patient had no pain meds whatsoever and according to D2 screamed thru the whole procedure.) She got physically sick and had to leave the room to vomit. Yesterday one of her 5th grade students came to school bleeding. She had been raped, either at home or on her way to school that morning. (At least that's what is suspected. The girl won't talk, but there's really no other explanation for an 11 year old's inner thighs, buttocks, stomach and genitals to be covered with scratches and human bite marks.)</p>

<p>She's also been doing hospice work for AIDS patients, besides the clinical work and teaching.</p>

<p>She is having a very hard time emotionally dealing with all of this and is having serious second thoughts about pursuing a medical career. I want to encourage her and tell that not all of medicine is not like this. But I don't want to do her a disservice by glossing over the bad parts of medical career.</p>

<p>I don't what to say to her. Her sister did medical volunteer service in Africa and likened her time in the South African townships to "putting a band-aid over a bullet wound", but found way to distance herself emotionally from the experience. I'm not sure that D2 will be able to do that. The suffering of others truly disturbs her on a profound level and is one of the reasons she wanted to be doctor--to alleviate it.</p>

<p>I guess what I'm asking is the doctors/med students on this forum have any words of advice I can pass along to her. Is there any counseling/classwork in med school that teaches med students to cope with seeing people in pain, with people dying, with seeing the very worst side of humanity? How do you cope?</p>

2

<p>The fact is that as a professional she needs to detach herself emotionally from what she is doing. Otherwise, she is not as good help (you have mentiooned that she herself felt physically sick and had to leave a patient. What if she is the only medical help? What if she leaves a patient, and he dies?). It is very hard to do and eventually she most likely will learn how. It is sad if a nice, hard working and dedicated person will be lost to the field of medicine. Maybe she needed to mature more before she took these trips? it is too late to reverse that. I am not in medicine at all. However, my D. is starting Med. School in less than 5 weeks. I would be discouraging her to go to other countries for different reasons. However, now I see that there is another reason to wait. There is lots of these going on in the USA, but not to the same level as in countries where young girl does not even have a status of human being.</p>

3

<p>An excellent question. There will always be events that break through even the most jaded physicians walls. One guilts up the mental capacity to separate emotions from ones actions, but that being said your d is being involved in some pretty heavy stuff for a premed.</p>

4

<p>I think the reason your D is pursuing med school is the most noble reason (IMO). She isn’t doing it for the fame or fortune but rather to help others and there is nothing more genuine than that. Try getting her to see the other side of this. She can be one of the few compassionate doctors/physicians who help their patients through tough times like this. The dark side of humanity clearly exists, but she can be one to help those victims cope with it. The care that she has is a great tool. She just needs to learn to utilize it to motivate her to go into medicine rather than become discouraged by it.</p>

5

<p>It may be too soon for your younger D to conclude that she can’t handle some of this. </p>

<p>Not all areas of medicine deal with intense pain and such. My H’s best friend is a cytopathologist and he doesn’t deal with patients/pain/suffering at all. Frankly, I don’t think he ever really “sees” patients other than their cells/slides/etc. </p>

<p>And…dealing with 3rd world medical treatments is very different from what she’d see in the US, where pain-management is very important. I would think that when she’d encounter patients with intense pain, she’d have an array of treatments to offer for relief. I think not having that option is what “got to her.”</p>

<p>I think almost anyone would become physically ill seeing someone suffer so much without any offering of pain relief. </p>

<p>BTW…I just heard that Americans consume over 80% of the world’s pain killers.</p>

6

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<p>Surprisingly, there’s very little medical school curriculum that deals directly with coping. Most med students cope by becoming jaded and detached. That’s probably the first thing you learn. I used to hang on my patients’ every symptom because I regard them with the utmost importance. Now, I learn to filter. If I’m on my ortho rotation, I focus on my patient’s back pain. I acknowledge they have ringing in their ears but I also know it’s not my job to work that up.</p>

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<p>It’s probably because you’re in Africa and there’s not enough pain meds. But, maybe the patient had a deep burn that took out all of her nerves and the doc didn’t feel she needed pain meds (the deepest burns are usually painless). We sometimes do surgical procedures where the patient is awake and they’ll scream even though they technically don’t feel any pain.</p>

<p>I’ve volunteered in Africa so I know what it’s like. Medicine here is obviously not practiced like that. But, one thing your daughter needs to accept is that there is a lot of suffering in medicine and usually we can’t do a damn thing about it. Everyone needs to find some sort of personal satisfaction in medicine beyond just “helping people.” You simply aren’t able to help everyone all that much.</p>

7

<p>She is seeing some extreme situations and in the very beginning of her process. Once she has learned to emotionally step back a bit, those horrid situations may still be nasty, but she may be more prepared to handle them. I would guess most doctors are not seeing people in that type of extreme. Yes, sexual abuse happens here and yes, burns happen here, but will most physicians deal with that? On a daily basis? Perhaps one working in the burn unit? DO hospitals in the US have ways to minimize that pain? I can recall in the 70s & 80s, reading stories about how horribly painful burn treatments are, but that was also when they did not give people with terminal cancer enough pain meds either. Would she be likely to run into things like that in the US?</p>

8

<p>In going through medical school, residency and being a physician it is inevitable that one will witness a great deal of tragedy and human suffering. It was not always easy for me to come to terms with it and I think most others in the profession have had moments of doubt about becoming a doctor. One should never become callous, but it is important to establish and maintain a certain amount of emotional detatchment from your patients. This is far easier said than done but most medical students achieve it to a certain extent by the end of their third year clinical rotations.</p>

9

<p>cool recent article about medical students and the D word (death) and how doctors become emotionally detached.</p>

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<p>[Doctors</a> and the ‘D’ Word - NYTimes.com](<a href=“http://well.blogs.nytimes.com/2011/05/26/doctors-and-the-d-word/]Doctors”>Doctors and the 'D' Word - The New York Times)</p>

10

<p>How old is your D? It takes time, and gradual exposure perhaps, but I think being fascinated with how the body works, more than “helping people”, is part of what makes doctors “tick”. And pain and death is part of that. I wince when people say they want to be a pediatrician because they like kids. You have to be able to see them in pain, maybe even cause them pain. And you have to be there when they die.</p>

<p>BTW, I did some time in Africa (Nigeria) too, but nothing like your D. I still kissed the ground when the got back.God bless !</p>

11

<p>It’s very tough. I couldn’t do it. No way. But, and this is stream of conciousness post here, I liken it to something I can do. </p>

<p>In my type of law practice, I see some horrible things and (from time to time) represent some horrible people who have done those horrible things. There are lawyers who just …can’t… do… it. They find other areas to practice, they drink, …or they quit. </p>

<p>What keeps me in the game, mostly un-jaded, is my role in the big process. Without someone like me, the system fails. “Even a werewolf deserves representation.” If you don’t accept that as tenet of your “professional faith”, don’t be litigator. It will eat you up. </p>

<p>So…maybe try to get her to realize her part in the process of health care delivery to these folks. If not her, who is there will do it? And if she knows (as I would know) that she …just…can’t…do…it, then find another area to practice, …etc.</p>

<p>I felt that way as an idealistic freshly minted lawyer working in Poverty Law. I quit after less than a year. At the end of every day, at the end of every week, at the end of every case, my client was still poor. I …just…couldn’t…do…it.</p>

<p>But this other thing? Representing werewolves? I can do that. For a little while longer , anyway. ;)</p>

12

<p>The hardest part of medicine, I think, is accepting which things you’re not going to be able to fix. What helps me is finding the ways that I can make it somewhat better. The ways that I can help, even if it doesn’t make a difference in outcome. </p>

<p>One of the things that made me think about this issue a lot was being on a geriatrics service earlier this year. There was an acceptance that a lot of our patients didn’t have a lot of time left. On that service, a “success” was getting a patient home to his/her family before they died. We made sure that they didn’t die in the hospital if at all possible. Often the patient and his/her family knew that time was short, and at that point what they really wanted was to be at home, in no pain, and close to their family. And most of the time we could do that.</p>

<p>In medicine big cures are great, but the small things (or the things that feel small) count too.</p>

<p>PS, child abuse is something that I still have not been able to come to terms with in any way whatsoever. I think it’s probably the hardest thing that anyone working with kids has to deal with.</p>

13

<p>Thank you all for your thoughtful messages. D2 turned 21 shortly before she left for her program. She is some ways a very mature individual and in some ways still quite naive about the world. Like I said she is very much an idealist and wants to believe that most people are “good” and the world can be better place than it is. I guess this trip has been her baptism by fire.</p>

<p>D1 got home from Europe last night and we talked. D1’s experiences in Africa mirrored D2’s in many ways. She will talk with her sister when D2 gets back in 10 days.</p>

<p>I also talked with D2 again this morning. (Nothing like having a conversation in 1 minute chunks 'cuz her phone service keeps cutting out…) She seems better. She spent a good deal of time talking with one the nursing volunteers about dealing with blood, gore and inhumanity of human beings after her terrible day.</p>

<p>D2 is most interested in neurology–which is a relatively blood & gore-less field of medicine. She is Ok dealing with people who will never get “well” but who might get “better”. She’s keenly interested in neurology because she has a number of family members, including her dad, who have/had neurological disorders–Parkinson’s, myasthenia gravis. She’s spent a lot of time working in neuro rehab wards. </p>

<p>She also said her anti-malaria meds are making her nauseous all the time–so it might have been the doxycline and not the debriding that made her vomit. She’s had problems tolerating her anti-malarials and is now on her third different drug in 2 weeks.</p>

14

<p>No matter the field…it’s tough.</p>

<p>As a physician, you see people almost entirely at their worst. They’re sick, they don’t feel well, they aren’t the same people you meet at the grocery store even 20 minutes later. They tell you secrets they don’t share with anyone else - including spouses, siblings, their closest friends, or the police - and to be the most competent physician you must work to pry those secrets out of those that don’t want to share. They want your advice but then won’t do what you tell them. If you fail to do what they want you to do, they get angry no matter how right you are. Any pre-med that expects frequent thanks or patients who are grateful will be all the reward they need will be sorely disappointed. </p>

<p>I realize how horrible much of that sounds.</p>

<p>It does make the ones who do say thank you, who genuinely mean it, that much more rewarding, but it’s nothing one can bank on…and it’s often with the patients who are in the most dire of situations that totally surprise you and say thanks. Happened to me today with the parent of my absolutely most sick patient…I got goose bumps. Because of that rarity, you have to find other ways of finding reward or reframing the thought process or it will eat you alive.</p>

<p>My very first patient death, one in which I was actually a student/intern/resident directly responsible for the care of the patient was a child abuse victim. In a sense I was lucky, it wasn’t until early in my second year of residency that I was forced to go through such tragedy. Certainly it’s not something I’m looking forward to as my career progresses, I went into pediatrics in part because the focus is so different - it’s much more about getting kids back to being kids, not just preventing the inevitable. But I’ve managed to reframe my “success” by focusing on how am I able to do the most “good”. For lack of a better term there’s a “thrill” in being the last line of therapy in the PICU. There’s reward from “saving” children who in another situation might die without my intervention, but if I do what I’m supposed to do, they’ll get better and those days they spent in the unit with tubes from every orifice is nothing but a bad memory for the parents. But it doesn’t come without consequence and that’s the way I accept it. Even if I’m perfect, children may die, if I make a mistake, there can be long term consequences. In the end, that paradigm of paying the price for the exquisite reward extends to all fields of medicine regardless of the acuity of patients…going into PM&R is full of stories of people walking again, but also of the patients who experience progressive deterioration. Being an OB/Gyn means sharing in one of the most thrilling and most significant days in a person’s life but also being the one responsible for telling a young women she’ll never experience that joy. The dermatologist who wants nothing more than the confidence of their patients to shine through will have the patients who end up horribly scarred…Okay, so maybe not all fields of medicine are equal (;)) but you get the point. </p>

<p>It’s great that your older daughter is able to help out and that D2 was able to talk to someone locally about her feelings. Mentors are vitally important in situations like this (though sometimes, even when you’re a really competent resident with a strong relationship to an experienced mentor who knows the field, you can be left wanting…not that I’m <em>blaming</em> my mentor for such an incident…okay maybe I am). A close, trusted mentor can ease the process, but in the end, your daughter has to make the decision for herself. There are absolutely ways to still be involved in healthcare, to still be involved in those success stories without going to med school. That said, I (obviously) think that the rewards in medicine are so much higher than they are in other fields. The only way that can continue to be true is that the failures have to be reciprocal.</p>

15

<p>I can go on and on and on…but will try to keep it short…</p>

<p>Needless to say, there are lots of other coping mechanisms. The gallow’s humor that pervades medicine is significant. I would never want parents of my patients to hear the things that are said behind closed doors when I’m with other residents. I frequently shudder and wonder how it looks when I’m laughing or joking with my fellow residents while in the PICU or NICU, completely unrelated to those parents are having one of the worst days of their life. The stories that get told over pizza and beer at a restaurant with other physicians, I can only imagine the horror of the people sitting at the next table. It’s not uncommon for me to recognize just how awful I sound only after having talked to my parents on the phone and realizing they didn’t laugh one iota at something I had been chuckling about all week. As someone who loves hospital medicine, I forget that spending ANY time in the hospital is not a normal thing.</p>

<p>Normal for a healthcare worker far exceeds the comfort level for a layperson.</p>

16

<p>WOWM:</p>

<p>You can call it callousness, but I prefer to think of it as a shift in paradigm. As BRM said, health care workers, especially those who work in a hospital, see people at their worst every day on the job. For us, “the worst” becomes “routine,” and so things that do and rightfully should horrify people outside the field are ordinary to us. If these things weren’t routine, we couldn’t do our jobs well.</p>

<p>The process of transforming “the worst” into “routine” takes time, and for most people, it happens during medical school and residency. Experiencing these distressing things in a group with your peers (fellow medical students or residents) lessens the horror because it’s shared with others - you feel that other people understand what you’re going through, and if one of you can make it out of there without retching or bursting into tears, then you can, too. It sounds to me that some of what’s made this so hard for your daughter is that she doesn’t have a peer who’s gone through this all just as she has. Support that you or your other daughter can give her should be helpful. If she does decide to go to medical school, I think the process will be less difficult because of that shared group experience.</p>

17

<p>I agree with shades_children that having a peer group of other students or residents is vital. </p>

<p>I would like to add that for I have been working in a hospital in an underdeveloped country for the past five years. We have 4th year med students from the U.S. and Europe rotate through at times. Without fail, all of the female foreign med students have broken down and cried at some point during their rotation. (The male students also experience stress, but express it in other ways.) It is very hard when you are dealing with tough things without your normal support system. </p>

<p>After over twenty years of experience as a pediatrician, I have seen more than my share of abuse cases. Although I have learned to deal with it in a professional way, it still horrifies me. It is even harder to deal with in another country that has a weak or non-existent child protective system. </p>

<p>The malaria medicine probably contributed as well. I remember doing an international rotation as a 4th year med student. I was scheduled to be in the OR and had been up all night with diarrhea. After being fully gowned in an un-airconditioned OR, I began to feel faint. The surgeon thought I couldn’t handle the “blood and guts”, but it really was just the combination of the above factors.</p>

<p>Hugs to your daughter. She will be a great doctor!</p>

18

<p>@BigRedMed</p>

<p>I also found myself engaging in the type of gallows humor that would sound simply horrible to people not engaged in the medical field as a medical student, intern, resident and practicing physician. I think it is simply a defensive coping mechanism we have developed so that we can continue to function in situations where we would otherwise break down in despair.</p>