Blog

Leadership II
Physicians Leading | Leading Physicians

The Critical Window of Medical School: Learning to See People Before the Disease

Blog Post · August 7, 2017

Imagine two identical groups of kittens. We’ll call them vertical kittens and horizontal kittens because of how they are to be raised. The vertical kittens are raised in a world that only contains vertical lines. Their cages are lined with vertically striped wallpaper; even the people who feed them wear shirts with vertical stripes. The horizontal kittens are only ever exposed to horizontal lines. Horizontal lines are all they see. You may by now recognize this story as one of the foundational experiments in neurobiology, but let’s go back to the cats.

After a predetermined period of time, the horizontal kittens are presented with a chair. They see the seat, and jump to sit. No problem. But they repeatedly walk into the legs. They simply don’t see them. The vertical kittens are presented with the same chair. They can’t find a place to sit — they are blind to the horizontal seat — but will happily weave in between the vertical legs.

This classic experiment by David Hubel and Torsten Wiesel provides some of the best evidence we have in support of the concept of “critical windows” of development. The brain, it seems, must be exposed to certain things, or it will wire itself to neglect them. It will dedicate its resources to wiring for only one orientation.

This idea of critical windows extends to many areas: language, culture, and manual dexterity. Though the length of time the critical window is open varies, in some fundamental way, we are all wired by our exposures.

Now instead of two groups of kittens, imagine two groups of medical students. We’ll call them the pathology group and the humanistic group. The pathology group is exposed to the classic medical curriculum. They study the disease state in minute detail. They train their eyes to see pathology. They memorize the clotting cascade that allows blood to go from liquid to solid through a divine sort of chemical reaction. They study rashes by feeling raised bumps on simulated skin in a lab. They train their ears to hear subtle murmurs in hearts by listening to endless audio repeats of the same murmur transmitted by headphones.

The humanistic group studies disease as well, but within the context of people. The pathology is given a human anchor from the very beginning. They meet people who have lives and feelings and preferences. These people have diseases and they talk about them. As the medical students learn the coagulation cascade, they hear patients describe what it means to take a blood thinner. How, because the patients are unable to eat salad every day, they worry they aren’t able to make healthy choices. These medical students understand the heart murmur in the context of addiction. They follow the trail from the years living on the street and injecting heroin, to the vegetation and the emboli. They hear and unpack expressions of guilt and feelings of remorse. They learn to see people before the disease — sometimes messy, utterly complicated, and vulnerable people who happen to have disease.

After the critical window of medical school, the pathology group is exposed to patients. Like the cats bumping into the legs of the chair, they see only disease. When the person in front of them asks for an explanation of why they developed a nearly fatal blood clot, the student doctor can eloquently describe the clotting cascade, and the pharmacodynamics of drug he or she will prescribe to disarm it. When the patient cries, the student doctor is blind to it.

The humanistic group, exposed to the same patient, is wired to see the emotion, before the tears even begin. They hear the tense pitch of vocal cords stretched by false bravery. They comfort. They acknowledge how frightening it must have been to be diagnosed with a clot, and at such a young age. The patient, buttressed by understanding, is able to express a fear that it will happen again. This patient and clinician possess the necessary knowledge so that together they can co-create a plan of care that alleviates that fear.

Our training wires us either to see, or to be blind. And as such, medicine suffers from a problem of orientation. For years it has been training students to only see disease, to identify pathology. The system is configured to produce a predictable product, and the product is then tasked with roles it is not trained to manage. The number of medical schools with curricula rich in emotional intelligence and situational awareness is vanishingly small. And given the weight of clinical knowledge that must be conferred during those short years, it’s no wonder. There is so much to know. But this knowledge comes at a price. Many students are simply not trained to see and respond to emotion. They have no toolkit at their disposal for a grieving mother. No words that come easily to assuage guilt. This misalignment between their purpose and their skillset creates feelings of isolation for all involved.

But the problem is far deeper. Let’s further disadvantage the pathology group. They will be trained in the ancient medical art of aequanimitas. It dictates that they are to maintain a coolness of mind in all circumstances. A sort of imperturbability, regardless of circumstance. They will learn to detach themselves from their emotions. Emotions that may cloud their judgement and muddy the sterile field. They will be trained to ignore hunger, thirst, and fatigue in pursuit of disease. They will be systematically disembodied. Those who find this difficult are given the option to escape through addiction, attrition, or suicide.

To disembody doctors and expect them to somehow transcend that handicap and be present in their bodies, empathic and connected, is disingenuous. They are vertical cats in a room of horizontal surfaces. We have not wired them to succeed. Physicians who have had to learn to disengage from their own emotions to function naturally divert their gaze around the emotions in the room.

And medicine cannot heal in a vacuum. It requires connection.

The humanistic group is taught to view this purposeful handicapping as an archaic coping mechanism. Instead, they participate in reflective writing, to examine their own feelings about suffering. They are trained to respond to emotion using improvisational actors playing the part of patients. They learn the pathways of synthesis and metabolism of bilirubin, while spending portions of their day in art museums, learning to see color and detail in paintings. This helps them to notice subtle pigmentation change in their patients’ skin, attuning them to early signs of hidden cancers. They are trained in the vast and varied textures of medicine as a human art. They achieve longevity in their careers. They set purposeful boundaries and find their interactions with patients to be so meaningful that their own lives are enriched. They revel in the work.

As medicine once again finds itself at a crossroads, with an impending physician shortage looming and less than half of physicians stating they would re-choose medicine as a career, we must take care to ensure that the solutions we propose are actually holistic. To increase the number of students matriculating or federally fund more residency positions without critically reexamining the training itself would do nothing but create more barriers to understanding. We have dedicated our resources to wiring the brains of young doctors to only one way of seeing. They are wired to see disease. They are wired for neglect. But they can be wired for so much more — more depth and beauty and empathy. And everyone, physicians and patients alike, deserves for them to be wired for more.


Recent Blog Posts

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now