Maintaining a moral compass in medicine

Jeffrey Lee
Philadelphia, PA, USA

 

The Doctor.” Painting by Sir Luke Fildes, 1891. Location: Tate Gallery, London
Fildes the doctor

It seemed like just another day during my third-year surgical rotation until I heard Mrs. W. cry. It was during daily rounds in the bustling ICU, and our team was squeezed around a single computer outside another patient’s room. I tried my best to pay attention to our discussion, but the cries from the elderly woman in the adjacent room distracted me. Mrs. W. repeatedly cried out, “Help! Help! I’m in pain!”

I struggled between whether I should continue to listen to my attending physician or help a patient who clearly seemed to be in pain. I was also troubled by the lack of response from my colleagues. They had obviously heard the woman — a few had even turned their heads at her loud cries. Perhaps there was a bystander effect going on, but the situation felt dehumanizing, which frightened me. Was this reflective of a medical system so goal-oriented that it plows past anything not directly related to the task at hand?

After an endless minute, I put on a gown and stepped inside Mrs. W’s room. She sat slumped in a chair next to her hospital bed with a web of IV lines draped around her frail body. As I tentatively approached her, she started to sob and exclaimed how much pain she was in. She wanted it to “just go away.” I reached out and held her weathered hand in silence, trying to be present with her pain but at the same time hoping my team would not leave me behind. I stepped outside the room a few minutes later and asked the nurse about her pain medication. The nurse replied, “Oh, don’t worry about her. She does that every time people stop outside her door. Just ignore her. She got her dose already.” I glumly trudged back into her room, feeling helpless. Mrs. W. barely made eye contact and kept repeating the same words. So, I simply stood there, stroking her hand and hoping my presence would have some effect.

A few minutes later, I quietly returned to the group, where apparently no one had noticed my absence. I wanted to speak up, but was almost certain that I would either be ignored or even penalized for interrupting. Medical students experience the struggle between attending to a patient’s suffering and appearing obedient to the hierarchy on a regular basis. I found it a disappointing reality that medical students must make such decisions.

I experienced similar situations throughout the year, such as feeling torn between spending time listening to a patient’s story about her recent psychological trauma and wondering if my preceptor was going to be angry at me for wasting so much time. I had been told to adhere to a fifteen-minute timeframe and was challenged by an unfair dilemma: is this person’s suffering worth my time? I constantly focused on how fast I could get each patient out of the office without appearing to rush them. This concern made me think less about providing thorough and empathic care for the patient.

On the last day of my surgical rotation, I came face-to-face with a similar predicament. I had hurriedly followed my resident down the hospital halls on a late Friday afternoon to help insert a feeding tube. When I walked into the room, I was surprised to see Mrs. W. once again, now out of the ICU. I took this as a good sign. We began the procedure by pushing the tube down her nose while telling her that this was the worst part and that we would try to be quick. Unfortunately, half an hour later, we were only a quarter of the way there. The resident let out a sigh and told us he was going to take a break. Someone had to hold the tube in place or else everything would come undone, so the fourth-year medical student and I dutifully took the resident’s place. We were waiting for an X-ray to ascertain the location of the tube, which meant we were going to be holding the tube for some time. As the minutes ticked by, Mrs. W. began to chant once again, “Help me, help me…” My back started to ache from standing in an uncomfortable position and beads of sweat began to trickle down my brow.

Initially, I paid attention to Mrs. W. and comforted her, just as I had before. However, she continued to wail louder, so I held her hand while staring at the TV in the corner of the room, doing my best to breathe and not let the situation bother me too much. I wondered whether these were the conditions that fostered apathy among many medical professionals. I thought about a resident at the end of a 24-hour shift, running around the hospital answering countless pages and dealing with difficult patients. Under these conditions, medical professionals can easily treat patients as items on a checklist rather than human beings in need. I started to realize that one can become worn down by engaging with patients without fully resolving their issues or receiving gratitude from them. I began to wonder if it was ever okay to temporarily tune out the cries of a patient if nothing I did seemed to help. Although I did not outwardly cause harm to Mrs. W by ignoring her, I felt that I was implicitly disrespecting her by not giving her my full attention.

Eventually, the X-ray machine arrived, and we were able to finish inserting the tube. However, I left the surgery rotation feeling ambivalent. I felt like I did the right thing during my first meeting with Mrs. W., but this later interaction left me wondering whether I should have done something different. Had I learned the frightening ability to selectively turn my empathy on and off?

Perhaps there are select times when doctors ought to turn off empathy in order to focus on the task at hand. However, I am troubled by the idea of donning a mask of empathy each time I enter a patient’s room, only to remove it the moment I leave, voicing words of appeasement rather than responding authentically to the patient’s current worries.

It is easy for medical students to lose themselves in the hierarchy of healthcare. From the start of clinical rotations, the system is set up so that medical students’ grades are dependent on the opinions of residents and attending physicians. Medical students quickly learn they must always appear competent and compliant. However, only doing what makes us appear compliant may sometimes compromise our commitment to relieving a patient’s suffering. Perhaps the culture of medicine rewards conformity over integrity. If so, we need to ask ourselves whether we are merely acting for the sake of appearances, which can lead to disrespect and callousness toward our patients.

As I progress through my journey in medicine, I will continue to face difficult situations where I am forced to choose between attending to my patient’s needs and simply obeying my superiors. I know I will sometimes fail by hiding in the background, but I hope that by honestly reflecting on my encounters that I will continue to realign my moral compass for the benefit of myself and my future patients.

 


 

JEFFREY LEE is a third-year medical student at Sidney Kimmel Medical College. He graduated from the University of Washington, where he studied neurobiology and philosophy. He is interested in utilizing reflective writing to maintain empathy throughout his medical career.

 

 

Winter 2019  |  Hektorama  |  Education