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Chapter 4, The Caregiver’s Perspective, by du Pre’ (and other sources): Notes Medical School Socialization and Curriculum: Socialization refers to learning to behave appropriately within a specific community. Healthcare professionals must be proficient in the Voice of Medicine. The voice of medicine entails carefully controlled compassion and a concern for accuracy and expediency. As students progress through medical school, attempt to assimilate into the medical school culture. They learn what is expected of them through observation, formal rules, and informal conversation. They are subjected to rewards (friendly behavior, popularity, etc.) and penalties (regarded as rude, etc.). Two years learning scientific material; 2 years in clinical experience; 1 year of internship; 2-7 years of residency. Medical students can officially be called “doctor” after 4 years. The Culture of Medical School: Loss of Identity: Compared to a military boot camp. There exists a strict hierarchy and those low in the hierarchy are reminded of their lowly status. “Medical Student Abuse” is term referring negative acts or words unnecessarily harmful, injurious, harsh, or insulting in the medical school environment. In one study (Sheehan, Sheehan, White, Leibowitz, and Baldwin, 1990): 85 % of medical student reported being yelled at or shouted at in a humiliating way; 73% reported being reprimanded with curse words; 23% reported being threatened with physical harm, mostly by patients; and 16% reported being physically attacked. Novices are frequently called upon to do “scut work” which refers to menial chores no one else wants to do. The chores are designed to humiliate novices. “Scut monkeys.” In spite of the lowly status within the system, medical students report feeling superior to those outside the system. Privileged Status: Doctors are granted prestige, money, and power. They experience things most people do not such as dissecting cadavers. In her memoir, A Not Entirely a Benign Procedure, Klass (1987) compared her experience to being initiated into the priesthood. People often experience a feeling of “elation” when called “doctor” the first time. Overwhelming Responsibilities: Nearly half of medical students surveyed (Sheehan, 1990) stated they felt they were placed in situations they weren’t ready for such as drawing blood from AIDS patients. Sleep deprivation is common. Residents may work 36 hour shifts and log 90-120 hours a week. Sleep deprivation leads of many negative consequences such as irritability, forgetfulness, mistakes, etc. 97% of medical students said they provided substandard care as a result of sleep deprivation (Sheehan, 1990). However, many feel it is a “unfortunate but necessary” part of medical education. Withdrawal and Resentment: Phillip Reilly, author of To Do No Harm (1987) remarked that his extreme exhaustion led him to resent patients. Often medical students come to think of patients are enemies. Also, disease is often thought of in physical terms. Thus, “The kidney transplant in Rm. 406 is more manageable than “The weeping daughter in Rm. 406.” Medical school customs serve 4 important functions: 1. High pressure environment may prepare medical students for the real world. 2. A clearly defined chain of command may help medical teams make decisions and carry them out. 3. Hardships of medical school may strengthen group membership and unite them together with a strong sense of enduring camaraderie. 4. The time in medical school serves as a long rite of passage and medical students may feel a strong sense accomplishment as they qualify. Medical School Reform: Most medical schools now provide training in psychological and social aspects of illness. Examples may include communication skills training, management and business, end-of-life care, and ethics). Harvard Medical School now has an innovative 3-year program in doctor-patient relationships. Some schools pair medical students with mock patients who provide feedback about their bedside manner. New rules are being drafted to limit number of hrs. med interns and residents are on duty. National Accreditation Council for Graduate Medical Education state should not work more than 80 hrs. per week for no more than 4 weeks without a day off. Schools not forced to comply but medical schools requiring more than 100 hrs may not pass accreditation. Some criticism of the new reform efforts: Working around the clock may allow interns to see how patient conditions change over time. Otherwise, interns will have naïve images. At some point, will instruction in people skills impede instruction in science? Stress: Stress is defined as an “Adaptive response, mediated by individual characteristics and/or psychological processes, that is a consequence of any external action, situation, or event that places special physical and/or psychological demands on a person.” Stress is NOT merely nervous tension and is not necessarily something to be avoided and can have positive consequences. The absence of stress is death! Consequences of stress and burnout are: Physically, stress is related to a higher risk for heart disease; sleeplessness, fatigue, weight changes, digestive disorders, headaches, etc. Psychologically, stress is related to depression, irritability, defensiveness, low self-esteem, etc. Stress and burnout have organizational consequences. People who are burned out may miss work, become apathetic, quit their jobs, etc. Burnout is a stress related development involving three elements: (1) Emotional exhaustion (the core): Feeling drained, tired, used up (2) Depersonalization (seeing the world through “rust colored glasses”): Tendency to treat people in an unfeeling, impersonal way. May come to resent people they are treating. (3) Feeling of a lack of personal accomplishment: Involves feeling like a failure. Person may become depressed, experience low self-esteem, and may leave his/her job or avoid certain tasks. Suicide rates for doctors are three times higher than the national average. They suffer higher-than-average rates of drug abuse and eating disorders. Causes of stress: Conflict: Results from many factors such as competing and ambiguous demands. For example, nurses feel stressed working holiday sand weekends or when interrupted by phone calls and various demands. Furthermore, nurses report a high degree of stress when they are required to carry out treatments they believe are inappropriate. This places them in a doublebind (there are negative consequences no matter which option they choose.) Emotions: “Emotional labor” can make work draining. It refers to the demand to generate and display particular emotions deemed appropriate to the situation, even when those emotions are not felt. For example, nurses may feel compelled to always appear happy and concerned, even when they are not. Communication Deficit: Communication plays a central role in the experience and management of stress. 1)
Stress can be created for workers if they are given too little
information (making them feeling uncertain) or too much 2) Burnout is more likely among nurses who are excluded from decision making (Ellis & Miller, 1983). 3) People are more susceptible to burnout if they do not feel they are skilled communicators. In one survey, physicians who viewed their communication skills to be below average also reported a low sense of personal accomplishment and a tendency to treat people in impersonal ways (Ramirez, 1996). Workload: Excessive workloads, monotonous work, and intense situations can all lead to burnout. For example, a person who does the same job all day, such as lab technicians, are likely to feel stress. Likewise, nurses who deal with emergencies all day will likely experience stress and possibly burnout. Other factors: Not everyone reacts to stress the same way, and certain environments, jobs, etc. experience stress differently. For example, surgeons have higher stress levels than doctors but are less likely to burn out from stress due to the benefits of the job. Radiologists report the lowest stress but highest sense of dissatisfaction so they have the highest burnout rate due to a sense of isolation and unappreciation. Buffers: Buffers alleviate burnout by buffering its effects. Examples may be extra staff and equipment at peak work periods, support from “top” management, increased freedom to make decisions, recognition for accomplishment, time off, equitable rewards, etc. Empathic Communication Model of Burnout: Compassionate people may be drawn to helping professions but may be susceptible to effects to stress and burnout. Detached concern (concern for what the patient feels is different from emotional contagion (feeling what the patient feels) and leads to more effective outcomes, such as communicative responsiveness (being able to communicate in appropriate, helpful way with patients), and occupational commitment. Communication Skill Builders: Tips for Avoiding Burnout
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This website is maintained by Marceline Thompson Hayes, mhayes@astate.edu This page last updated August 21, 2007 Arkansas State University |
