Tuesday, November 13, 2007

PostScript




Traumatic Disconnection
by Nick Gavin


As a new clinical medical student interested in social determinants of health, it’s usually easy for me to understand my patients’ feelings and identify with how they are responding to particular situations. However, at times there is a lapse in empathizing, and I can’t help but wonder how patient care is being affected. This disconnect between me and my patient was never more apparent than on my trauma rotation. Each time I walked into the resuscitation unit, a similar scene was laid out before me: young, male, low socioeconomic status, wrong place, wrong time. While this was somewhat expected (particularly in penetrating trauma cases), what I did not expect was the fatalistic mentality of some of the patients. A common refrain sounded like:

“This is just a fact of life when you’re on the street.”
Each time, I couldn’t help but compare my patients’ situations to my own—after all, most were my age. The facts of my life include working, studying, eating out, going out with friends. Being shot would be traumatic. Watching my patients’ casual behavior, I couldn’t help but wonder if some of these injuries had the same effect on them. Maybe the scene was too familiar, or too common where they come from. It seemed as if the trauma had been blunted in some way by the expectation of one day being shot or stabbed.

This is what I could not understand. I simply could not relate to this brand of fatalism, the kind tinged with pessimistic resignation. Bridging the gap required me to think about being raised with the expectation of eventual or continuous trauma. Imagining just how many kids are raised in this state was frightening. It also made me realize that primary prevention of penetrating traumas had almost entirely to do with preventing this state of mind in the first place. My question now is: how should emergency physicians step into this preventive role? And how will my generation of EM physicians “treat” these patients differently, if at all?

Implications

In medical education, there is an intense push to impart the value of empathy and understanding on medical students. For most students, there is little struggle in “feeling for” patients but often it can be difficult to communicate this true concern — patients often come to the encounter with biases and assumptions about their caretakers which make it difficult for students to seem authentic. Sometimes, though, the biases and experiences of the provider, or in my case the student, sneak into the patient-physician relationship and interfere with the understanding of the patient’s situation, creating a gap between the patient’s reality and the provider’s spectrum of comprehension.

Empathic relationships with patients are essential for trust of medical institutions generally and rapport with each of us as physicians. Sometimes the path to empathy is not natural, and requires a little thinking. Maybe the seed of policy solutions lies in that thinking.

Nick Gavin is a third year medical student at NYU School of Medicine who is interested in emergency medicine and the sociology of health care.

12 comments:

Chrysalis Angel said...

What a great thing that you recognize the impingement of empathy, when faced with a mentality unlike your own. The diversity you will encounter will be part of the challenge, in your practicing your chosen field. I really like your blog. I hope you don't mind my stopping in.

Nick Gavin said...

Thanks for your comment. I think it's often viewed as a faux pas to admit that empathy is not always easy or natural, but I believe it's always necessary for the best care for the patient.

NPG said...
This comment has been removed by the author.
Anonymous said...

Well said young man - have only been an ED intern for 6 months - and am encountering within myself a cynicism i did not think I would develop - compassion fatigue I think - this needs to be addressed at med school with strategies to deal with it. some times I think the guarded/jaded mein that ED docs is a form of self preservation.

good blog

NZ ed doc.

Chrysalis Angel said...

Your right Nick, empathy isn't something that is automatic when you are facing some vial situations. It takes an adjustment at times to look through to the human being laying before you.

I think your other commenter is right also. There forms a detachment at times to protect yourself from the day to day fatigue that comes with rendering patient care. You need to wall off certain things, so you can move forward to be of help to others.

I hope those of you with a heart will not lose it. We need good medical people in place. I've linked to you, I hope you don't mind. You can contact me via email if you'd rather I not. Best to you.

Chrysalis Angel said...

I meant to type vile, not vial - if you can please correct that for me.

Prudence said...

I can relate to this post, as I also posted something similar to it in my health blog. It's about doctors facing death of patients most of the time more than the average person and seemingly "getting used" at the sight of it. I don't think it's simply about getting used to the idea of death occurring so regularly rather it's just that we've to learn how we should also protect our feelings. While that patients do need our compassion, we also have to protect ourselves from being too affected by the daily drama that usually unfolds before our eyes during work.

Anonymous said...

Nick,
Prevention? please. The incidence of penetrating trauma is a function of the economy. Jobs are the prevention. So, take a load off your back.
It is your task to find understanding and offer compassion to these patients. Over the years, you'll find you do have common experiences with these patients. The chasm you feel now will narrow.

NPG said...

I completely agree that "jobs" (aka education, occupational training, and economic sustainability) is the answer, however, I wholeheartedly disagree with the idea that my entire job as a physician is to offer care and compassion. That's definitely part of my job, but how is that useful to society? I am suggesting that also part of my job is to work with policy-makers, educators, and others to come up with wide-scale solutions.

Anonymous said...

Well said. I am not going on to med school but I am in the healthcare industry and I work in a hospital and I so much agree with your words and yes keep your heart because patient satisfaction is our goal and our job as we chose this profession. God Bless you.

Anonymous said...

Hi Nick,
I'm an RN student, and can intimately identify with what you are saying...it IS part of our job as health providers to address the prevention piece. That being said, I wonder, can that resignation to their fate that we see in these patients, once there, ever be removed? It is not only the young street people who live in this numbness, either, it is found in every marginalized population - the elderly, the uncomely, the poverty stricken, the uneducated, the disabled...the list goes on. These people are so used to being unvalued that they cannot begin to see themselves as valuable. It begins with that hopelessness and powerlessness to change things, themselves. Some of them can change - those lucky enough to get a break, if they recognize it, & if those habits of thinking and being are not so deeply entrenched in their identity that they can move beyond them. Some of them can't. What is our job? I think you're right, again, when you say your practice is less than it should be when you disconnect from the patient...I think health practitioners lose sight of that (those that ever were compassionate) sometimes, because of their own feelings of hopelessness to help these people to a better place. Maybe our job is just to accept and love these people where they are, as they are. Jesus said the poor will always be among us. We should be grateful for the blessings of wealth, education, beauty, intelligence and so on, if we have been given them, and we should use them to benefit others. And I think it's good to try to make changes when we can, but not to give up in despair if we can't. This has been such a hard lesson for me. I too, want to be an agent of change. Maybe I will find a way, but until then, I will just serve, and make a difference that way.

NPG said...

Thanks for your comment. And I'm sure your service is making a difference. I'd just like to take issue with one thing: you seem to be writing off this population as numb/hopeless/etc. While I agree that a lack of self-efficacy and self-advocacy definitely contributes to the health disparities experienced by urban youth (trauma being a great example), we should also explore how perceptions of the health system, health knowledge, health beliefs, and social capital affect behaviors (and therefore affect health). We can't write everything off as unalterable fatalism.