Physician, Humanize Thyself

By SALLY SATEL

'Be the kind of physician that you would want to have if you were sick." With these words, Dr. Arnold P. Gold welcomed the incoming class of medical students at Columbia University College of Physicians and Surgeons last month. As thrilled parents looked on, 168 young men and women sat expectantly in the school's auditorium, their white coats folded over their arms, each waiting to be called to the front of the room and "cloaked" by a senior physician.

This marked the 18th annual White Coat Ceremony at Columbia. Dr. Gold, a white-haired and avuncular pediatric neurologist, popularized the practice years ago because, he said, "medical students were becoming enamored of technology and were losing the important aspects of human relationships with patients." Columbia's chaplain referred to the coats as "cloaks of compassion."

I asked to observe the "cloaking" ceremony at Columbia because my generation did not have such a tradition in the early 1980s. As I recall, a secretary in the dean's office instructed us, most unceremoniously, to go to the hospital laundry and pick out a coat in our size.

This year, most of the 133 medical schools in the U.S. held white-coat rituals. The ceremonies are the centerpiece of a movement known as "humanism in medicine." It gathered momentum in the early 1980s when cost-cutting efforts imposed by insurance companies began to infringe upon the doctor-patient encounter. Physicians bristled as they were told how long their patients could stay in a hospital and how often they could schedule outpatient visits. Managed care, which blossomed in the 1990s, exacerbated this trend.

Proponents of humanism contend that these changes in the medical culture have filtered down to students, distorting their outlook as they progress through school. Indeed, numerous studies from the last decade or so document an increase in cynicism and loss of idealism in medical students during education.

Yet, this is hardly new. A 1955 paper in the Journal of Medical Ethics found that students' attitudes about patients became increasingly cynical with seniority. Surely, shielding oneself from the suffering of others with gallows humor, ritualized slang, or a detached bunker mentality, is as old as hospital-based medicine itself. Even so, advances in medical technology occur almost daily, and heavy reliance on diagnostic tests has partially displaced the more intimate activities of in-depth history taking and physical examination.

Fostering "humanism" is a big enterprise. A number of schools, such as the University of Pennsylvania, Ohio State University and the University of Medicine and Dentistry of New Jersey have assistant deanships and centers dedicated to "professionalism and humanism."

Mt. Sinai School of Medicine and a handful of others reserve a block of admission slots for students who majored in English, history, philosophy or other humanities but never took physics or organic chemistry. They also forego the MCAT exam, which is required of traditional pre-med students.

"A liberal arts background may provide these students with enhanced communications skills and improved bedside manner," says Dr. David Muller, co-author of a recently published five-year study on the Mt. Sinai program.

To expand clinical empathy, some medical-school instructors have students imagine the life of their cadaver and write about their feelings towards him or her. Penning confessionals to one's cadaver strikes me as gimmicky, but the basic idea is laudable. After all, respect for the patient as a unique individual is at the core of what it means to be a doctor. As the venerated physician Sir William Osler told students in an address at Albany Medical College in 1899, "Care more particularly for the individual patient than for the special features of the disease."

But the question of whether empathy can be taught—and, in particular, whether a white-coat ceremony is a good means for promoting that virtue—is a matter of some debate.

Judah Goldberg, a young doctor at Chilton Memorial Hospital in New Jersey raises an intriguing paradox. He asks how the white coat can bring doctors closer to the subjective experience of patients when, as an icon of the profession, it is meant to isolate and distinguish them from the lay community.

"To the extent that empathy can be taught through a ritual," Dr. Goldberg told me, "a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat."

As for the students, it is not at all clear that deep empathy as an intuition can ever be inculcated. I, for one, am skeptical. After all, the most humane physicians—like a Dr. Gold—tend to be humane people to begin with.

Nonetheless, basic fluency in the human dimensions of patient care, e.g. respectful attentiveness and a genuine commitment to a patient's welfare, can and must be instilled throughout training. It happens not in the classroom, of course, but, ideally, on the wards and in clinics under the watchful mentorship of seasoned physicians.

The fledgling medical students I observed will soon lose their innocence, naturally. Yet the policy climate that greets them will put the prospect of rich doctor-patient relationships under further strain.

The new Affordable Care Act, for example, will require hours of detailed coding and notes to justify billing, siphoning even more time away from patients. Guideline-driven care, depending upon how rigidly it is enforced, may well put physicians in the position of pressuring patients to accept certain treatments, irrespective of their choice.

Juggling the timeless injunction to all doctors—be a mensch—with concepts like "Medicare metrics" and "standardization," (the new watchwords in health reform) will make it even harder for the newly coated students to become the kind of doctors that they themselves would like to have. An induction ritual acknowledging as much wouldn't hurt.

Dr. Satel, a psychiatrist, is a resident scholar at the American Enterprise Institute and a lecturer at Yale University School of Medicine.