Thursday, December 26, 2013

From calluses to callousness: Interpersonal challenges in medicine

"Have thick skin," they often say.

At some point, though, thick skin wears thin. Or, perhaps even worse, thick skin grows too thick: it turns into calluses.

And with calluses comes callousness.

As we enter 2014, we face many well-recognized challenges and concerns in modern medicine: drug-resistance, surgical site infections, health insurance coverage, primary care physician shortages, etc. However, one challenge that we may have the most control over remedying is one that continues to plague hospitals and clinics daily: how we treat each other.

The Stanford Prison Experiment is alive and well in our healthcare systems, unfortunately. In 1971, twenty four male college students were randomly assigned roles of prisoners and guards and were asked to play out those roles in a mock prison. Within days, these college students were behaving in worrisome ways; in short, their role-playing became their reason for being. The experiment was stopped soon thereafter when one person finally spoke out about the abusive behavior that was occurring.

You be a nurse. You be a medical student. You be an attending. You be a nutritionist. You be a resident. You be an occupational or a physical therapist. You be a _______. We assign folks various niche roles in healthcare; providing medical care to patients is a team sport, whether we like it or not. No one profession--nor one individual--can carry out all the tasks and responsibilities needed to provide effective, efficient patient care. We need each other. We need interprofessional collaboration and cross-specialty communication. We depend on each other; and our patients depend on us: they depend on our teams to serve their health needs.

As a third year medical student, I often feel like a fly on the wall. In fact, frequently, I try to be a fly on the wall: "Speak only when spoken to," "Stay out of the way and make everyone's life easier," etc. are the mantras that (perhaps far-too-often) guide my day. In this peculiar role, I am able to serve as a quasi-objective third-party observer of the social dynamics that play out in various healthcare settings. I'm an outsider, after all; I'm merely passing through for a brief time: I spend two weeks on one medicine team, one week on an orthopaedic surgery service, etc. as I rotate through my clinical clerkships learning what each specialty of medicine does and, ultimately, what I want to do clinically with my career as a doctor. My clinical role tends to be ill-defined, and largely resident- and attending-dependent. Each day I wake up energized, grateful for the gift that I have been given, for the opportunity to play a (hopefully positive) role in healing people. I do my best to "be proactive" and try to "fit in" with the team that I am assigned to for that short stretch of training. I grew up playing sports, so I attempt to draw on my diverse experiences as a member of soccer, basketball, baseball, tennis, golf, and other athletics teams, many that performed at high levels. But what I find, over and over again, unfortunately, is that I feel like a witness to crimes against humanity, rather than like a member of a well-functioning, respectful team of healthcare professionals. Somehow, someway, the passion for healing is supplanted by complaints and by bullying: one profession complaining about another profession; one individual bullying another individual; and, the list goes on.

With lists of tasks to accomplish overwhelming healthcare providers--there are orders to write, drugs to administer, phone calls to make--and with healthcare providers operating mostly in silos--formal interprofessional collaboration is just starting to be built into our delivery systems--the statistical chances for miscommunication between and mistreatment of colleagues are high. The expectations of healthcare professionals are super-human. The environment for working is inhumane. And, the outcome is predictable: callousness. Personally, I sense myself turning callous when I starting blocking out things; I put "blinders" on--it's an adaptive response to a high stress, seemingly impossible situation. Without a doubt, hedging against this natural human tendency is challenging. But it's a challenge worth tackling.

We cannot reform our healthcare systems if we cannot first reform how we work, how we work with each other: how we treat each other. Misdiagnoses, unneeded tests, and other clinical errors result from poor teamwork, from healthcare professionals not working together in a professional, respectful manner.

At some point, it's not about having thick skin. It's about being honest with each other about the simple fact that we all are susceptible to feeling like our skin has worn thin. It's about recognizing that we are human beings; it's about appreciating our humanity--our reasons for being.

And we are all susceptible to the powers of role-playing. We have a forewarning: the Stanford Prison Experiment teaches us that our hospitals and clinics don't need to be prisons. Instead, they can be places that restore, places that heal, places that foster that passion that first motivated us to pursue the art and science of medicine.

As a hopeful medical student, that's my wish for 2014.

To good health,



  1. Excellent post! It reminded me of two TED talks I saw recently:

  2. Thanks, Bryan!

    I really enjoyed watching both of those TED talks. Complimentary messages. They both provided insights that medical culture could benefit from tremendously. I hope that we can find ways to embed those perspectives within our institutions. Like Dr. Goldman mentions, it starts with individuals who are committed to doing things differently; but, finding ways to link up individuals with that motivation in a more formal system can produce synergy and drive cultural change on a larger scale. That's something that I would love to facilitate in my career: working with folks like you as colleagues is inspiring!

    Happy Holidays to you and your family.