Making Tlc A Requirement

Doctors shouldn't be totally heartless," concedes Dan Dubin, 26, a fourth year Harvard medical student, "but there's no positive reinforcement for spending extra time with a patient." Handholding and comforting, he believes, are better left to nurses and social workers. Doris Iarovici, a fourth-year medical student at Yale, couldn't agree less. "With really sick patients, there often isn't that much a doctor can accomplish with science," she says. "One of the best things yo can do for any patient is to listen and show that you care."

Perhaps not surprisingly, Dubin plans to be a dermatologist and Iarovici a psychiatrist-but the debate over physician compassion cuts across every specialty. Who has it and who doesn't? Can it be taught? Is it always desirable-or can it interfere with objectivity and sound judgment? Many U.S. medical schools have recently introduced new courses in the doctor-patient relationship, and broad programs that include TLC as a requirement, not an elective. Not all physicians and students, however, are sold on the new emphasis. Dubin worries that Harvard's New Pathway program, with its focus on understanding the patient's emotional needs, may be sacrificing basic science knowledge. "A Harvard student may not be able to save someone from suffering a stroke," he says sarcastically, "but he will be able to calm the patient into not suing him."

A thoughtful new movie, "The Doctor," which opened nationwide last week, is certain to fuel the discussion. Based on the 1988 account of an Oregon physician's own experience, the film stars William Hurt as an arrogant, insensitive heart surgeon who develops empathy for patients only after he becomes one himself. Before his gradual transformation through a battle with cancer, Hurt wisecracks to worried patients, makes merciless fun of a more serious colleague and advises his surgical residents to "cut straight and care less."

In the movie, the reformed Hurt announces that all his residents will spend 72 hours as patients. "My fantasy is that before becoming a doctor you should either grow up in a house where someone is dying or have a serious illness yourself," says UCLA neurologist Dr. Bruce H. Dobkin. That's not something to wish on anyone, but, says Dr. Michael Wilkes, an assistant professor of medicine at the University of California, Los Angeles, School of Medicine, "somehow we need to put students through that role so they can understand what it's like." This fall UCLA will launch a required four-year "doctoring" curriculum. Directed by Wilkes, students will visit drug-rehab clinics and juvenile jails, and will interact with actors playing the role of patients. The program's goal, Wilkes says, is "to make sure the compassion and humanity students come to school with are not lost."

Harvard's New Pathway is an even more radical overhaul of the medicalschool curriculum. This year's graduating class was the first to spend a full four years in the program. Some of its innovations are cosmetic-changing course names from "Pathophysiology" to "Human Systems," and "Anatomy and Histology" to "The Human Body." But other reforms are profound. Students average only one lecture course a day and spend the rest of their time in small tutorials. While most medical students spend an entire semester dissecting a cadaver, New Pathway students give only eight weeks to basic anatomy. At the heart of New Pathway is the Patient-Doctor course, which brings students into contact with actual patients from the very first week of school (traditionally, clinical work doesn't begin until the third year). First-year students don't give physical exams, but they do interview patients at length. Debra Yu, 26, found a visit to the home of a 92-year-old patient with prostate cancer was particularly valuable. "Just knowing the patients helps you provide better care," she says. "You can't be taught how to be empathetic, but it gets ingrained."

The question remains whether such training will stick once medical students begin to practice. Already, Yu has had to withstand the bantering of traditionally trained residents who tell her not to spend so much time asking patients, "How does that make you feel?" But Peter Kaiser, 24, who plans to become an eye surgeon, maintains that "it only takes one or two minutes to be compassionate, to put patients at ease. I don't think I'll change. I don't plan to become one of those surgeons of old."

It's a common-though unproven-perception among both doctors and patients that surgeons tend to be the most insensitive of specialists. But they get high marks for surviving their grueling residency programs. They put in five to nine years of postgraduate training, for example, compared with three to six years for an internist. The hours logged by young surgeons are themselves a lesson in inhumanity. One second-year resident at a community hospital in Pennsylvania (who didn't want to be identified as a complainer) says, "In a good week I'll work an average of 100 hours. This week was bad; I put in 134."

There's more to the surgical mystique than the nightmare of training. Heart surgeons and neurosurgeons must maintain a certain protective distance, says Dr. Kevin Morrissey, clinical associate professor of surgery at New York's Cornell University Medical College, because more patients die in those specialties. "If you get too close too often," says Dr. David Roxe, a kidney specialist at Chicago's Northwestern Memorial Hospital, "the danger is burnout." Morrissey and other doctors are sure that the growing number of women in medicine (at a number of schools, female enrollment approaches 50 percent) will help humanize the whole field, including surgery. That's if they can tolerate the atmosphere in the meantime. Dr. Deborah Davis Ascheim, a second-year resident in internal medicine at New York Hospital, considered a career in surgery, "but it was almost like joining the military," she says. "The hierarchy was unlike anything else in medicine."

Given a choice, any patient would prefer a brain surgeon with a steady hand to one who can flash a warm smile. But with increasing competition by doctors and hospitals, patients can be demanding consumers. Tomorrow's physicians, whether they like it or not, will need soft hearts along with hard knowledge, to make sure that their bedside manners shine as brightly as their scalpels and stethoscopes.