The imminent death of a family member is riddled with emotions for family family members. The reasons are obvious.  But it's not just them. 

A paper based on the reflections of third-year Loyola University Chicago Stritch School of Medicine students sheds light on the struggle physicians in training often face when trying to control their own emotions while not becoming desensitized to the needs of the dying patient and his or her family. This could mean trouble in a future where human lives quite clearly have a cost. In the past, it was easy to demonize hospitals and insurance companies as not caring about patients, but now the people writing the checks are...us. The maverick M.D who puts patients first is being drummed out of existence by a 'teach to the protocol' environment and, soon, a culture where there is no one to rail against for putting money ahead of patients. 

Some desensitization was always needed. A doctor who is overcome by the circumstance of every patient isn't going to last long. But in the near future that line will be made much easier by regulations. Doctors will simply have no choices.

"Medical students are very aware they are undergoing a socialization process by which they become desensitized to the difficult things they see every day in the hospital. They realize this is necessary to control their emotions and focus on caring for the patients. On the other hand, they are very concerned about becoming insensitive to the spiritual, emotional and personal needs of the patient," said Mark Kuczewski, PhD, lead author of the paper in Academic Medicine
and director of the Loyola University Chicago Stritch School of Medicine Neiswanger Institute for Bioethics.

The work focused on a randomized group of Loyola third-year medical students who were asked to write an essay reflecting on their personal experience as part of a team caring for a dying patient. The students were asked to think about patient care, communication, compassionate presence and personal/professional development. The assignment was given two months into their clinical rotation and was to be completed five months later allowing the student to complete five of their required clerkships.

The essays were coded using a multi-step process and content-analysis approach. A bioethicist, physician and medical school chaplain independently read and coded the essays looking for emerging themes. The team then met together to compare themes and resolve discrepancies. Four themes emerged from the 68 student responses: communication, compassionate presence, patient care and personal and professional development.

The study found that conveying the prognosis of death to patients was understandably difficult—but not just the manner in which it was conveyed, but also who conveyed it.

"Students observed how their teams delivered and explained the prognosis. Conversely they also wrote how teams avoided it," the study reported.

"Students reported no matter how well a physician communicated a prognosis, families and individual family members absorbed and digested the information in their own manner and at their own pace."

The study also pointed out the importance of the medical team having a compassionate presence beyond routine medical interactions, such sharing interests, conveying affection or continuing to show interest in the patient after treatment had ended.

The study affirmed the importance of the medical care team understanding that a patient is body and soul, acknowledging there needs to be emotional and spiritual support for dying patients and their families.

"The students reported that some medical teams are very focused on the immediate medical problems. There is a fragmentation of medical care, such as teams rotating on and off service and patient transfers also that allows medical practitioners to avoid addressing the larger picture, death," Kuczewski said. This same fragmentation may cause practitioner to overlook patients' and families' needs for information and emotional and spiritual support.

The study determined that there is a need for emotional and spiritual support for the medical students and the health care team who are facing the loss of a patient as well.

"Though some students wrote that their team acknowledged in some way the death, others felt there was no closure. The team would move on to the next patient, leaving the student with unresolved feelings," said Kuczewski.

Finally, the study found that students struggled to avoid becoming desensitized to the human reality that their patients were experiencing while also learning to control their emotions.

"Students were aware they must temper their emotions to be patient-centered. Still, many were upset that increasingly they were ceasing to react emotionally to situations as they typically would have prior to their clinical experiences," said Kuczweski.

The study concluded that student reflections offer insights into the ways the spiritual needs of dying patients and their families are addressed in the hospital environment. Additionally, it is a glimpse into the personal and professional development of a person as they transition from layperson to physician and the need for medical schools to develop ways to support students during this transformation.