Author Danielle Ofri On The Challenges Faced By Medical Students
Dr. Danielle Ofri, author of the book "What Doctors Feel," speaks with Sound Medicine's host Barbara Lewis on the range of emotions and struggles faced by physicians. Dr. Ofri is a 20-year internist at Bellevue Hospital; an associate professor of medicine at New York University School of Medicine; and editor-in-chief of Bellevue Literary Review.
“Here’s a harrowing statistic for you. At least 300 doctors take their lives, annually. That’s like an entire medical class disappearing each year. So what’s happening to send so many doctors into despair?” asks Sound Medicine’s host Barbara Lewis.
Physician and author Danielle Ofri told us that the attitude shift from optimism to disillusionment can begin during training.
Ofri: Certainly when medical students start medical school they are brimming with empathy, professionalism, commitment, optimism. And when we study these traits we find that at the end of training, that many of these qualities have taken a beating. It seems to happen mostly during the transition from the classroom years to the clinical years. It’s something that seems counterintuitive that should be the flowering, one would think, of doctor-patient interaction. I think there are a number of reasons for that. One is that medical students, when they come into the real world of medicine, it’s much more chaotic and unpredictable than classroom life and they often feel very lost and useless. And they are constantly being shifted from different places. But even more so than that, is what we call the hidden curriculum. There’s the explicit curriculum they learn about the ideals of medicine: empathy, compassion. But then they watch how medicine is actually practiced. And I think they see that many of these important qualities are dispensed with when it comes to the actuality of patient care and they’ll observe senior doctors being disrespectful with patients; talking to nurses in a way that doesn’t communicate empathy and compassion; making jokes behind people’s back, about patients or other staff. And they say ‘oh, this is the way people really are doctors.’ And that contributes to a corroding of some of the ideals that students came in with.
Lewis: Not only do they face the new realities of a doctor’s life, like filling out all those forms, but some more entrenched challenges.
Ofri: Patients are very medically complicated. People have many chronic illnesses, acute illnesses; there are overlays of socioeconomic issues; people have been laid off from work; there are a lot psychological components; prior approvals needed from insurance. And all in 15 minutes. You either have to cut corners or you can’t do a good job. Either way, you don’t want to cut corners. You want to document appropriately and thoroughly And on the other hand, you want to spend time talking with your patient and examine them. But then if you take too long, the next patient has to way too long the other patient has to wait. Patient satisfaction goes down. Your productivity go down. Your numbers go down. It seems like you can’t win.
Lewis: Burnout doesn’t just have consequences for the doctor. It may be harmful for the person on the other side of the stethoscope, too.
Ofri: In order to empathic, you have to be able to imagine how someone else is feeling. Put yourself in their shoes and convey that. It’s very hard to focus on someone else’s issues if your own problems are dominating. It’s very hard to I think doctors who are burned out and disillusioned have a much harder time stepping out of their shoes to be empathic. Where this comes into play, is we have actually studied empathy and seen that patients and doctors who score higher on various empathy scales, these patients have better clinical outcomes. With their diabetes, for example; with their cholesterol, depression, and even with the common cold. You can imagine doctors that are very disillusioned and burned out probably do worse in the empathy department, so I imagine their patients likely do worse. Now we don’t have hard data for this part.
Lewis: Dr. Ofri is hopeful that the next generation of doctors will be able to tap into more resources of resilience as they go into their careers.
Ofri: In a recent large survey of doctors, it seemed that interestingly the younger doctors, the female doctors, the doctors in primary care seem to be the least disillusioned. I think the issue of generations plays a big role, and that it has changed a lot. And I think people went who went into medicine a generation ago, went into a very different field than we have today. Those coming in now, I think go in with their eyes open. So for people, who had a different image of medicine, they aren’t going into medicine now...The stereotype of doctors going into medicine just for money, I think that’s largely gone. All those folks went off to Wall Street. So who’s coming into medicine now? People who really want to be there. And that includes a much broader group: women, minorities, people from underrepresented communities are now coming into medicine. For many of these communities of people, they're striving very hard to be there and so thus, they are more satisfied when they get there. Most doctors have the good fortune of being healthy and we never really experience what it's like being ill. Certainly having a baby is not being ill. But it is an experience of being vulnerable, dependent, not able to do many things for yourself. I remember my first child which I gave birth to in my own hospital. All things were so important as a patient....I remember after the delivery, they give you that frosty pitcher of water that you’ve been waiting for all day. For me, the pitcher was just out of reach. And I couldn’t just jump up and grab it... I remember, at that moment, that pitcher of water was the most important thing in the universe. And I didn’t care who was dying in the next ward over. I know, as doctor, there are many sicker patients on the ward that need more attention than my cup of water. But I didn't care as a patient. And I kept calling and calling, and when it finally came I finally realized this is the most important thing for me. And now, when I see my patients I know that their medical care is the most important thing. But when they need a ginger ale or the box of tissues at that instant, that’s the most important thing. And if I can just take one extra minute to attend to that, I think the patient then feels like they are really being taken care of. They're not being ignored or shunned to the side. I really learned about those seemingly small things take on a great importance when you’re ill and vulnerable.