Here Be Dragons

I got this message from the Arnold P. Gold Foundation the other day. It was a about how and under what conditions compassion or empathy manifests. It started with a quote from a researcher about the brain origins of compassion and what influences it:

“It turns out that feeling safe is a precondition to activating biological systems that promote compassion. In the face of another person’s suffering, the biological mechanisms that drive our nurturing and caregiving can only come online if our more habitual “self-preservation” and “vigilance-to-threat” systems (e.g. fear, distress, anxiety, hostility) are not monopolizing the spotlight.” –

Stephanie L. Brown. “Placing Compassion in a Neurobiological and Evolutionary Framework.” The Science of Compassion: Origins, Measures and Interventions [Conference]. Telluride. 19-22 Jul. 2012. See the video above.

And the question posed in the message to us was, “So, how do the anxiety and fear that medical students experience as part of their education and training impact their ability to develop compassion for their patients?”

I can remember many times of great anxiety during my medical school days. In fact, I am regularly anxious in my practice as a psychiatric hospitalist even nowadays. Over the years, I’ve often wondered how empathy survives the typical education of a doctor.

As a second year medical student, during a simulated patient exercise in which I was supposed to conduct a pelvic exam on a woman acting as a patient, I noticed that the female facilitator seemed to be nearly as nervous as I was. I remember very little about the exercise other than making a supreme effort not to dash out of the room in terror. I probably scored less than average on display of compassion that day.

As a psychiatry resident and still now, I participate in behavioral emergency management events we call Code Greens in the general hospital. They typically involve very sick patients with delirium who are often terrified and become threatening or violent. I can’t recall compassion being the uppermost emotion during these crises.

In an academic medical center like this one, we round on patients as a group, often with the medical student leading. Sometimes the patients are pretty frank about letting students know what they think of their rank, which can lead to their feeling demoralized and deskilled.

Commonly, I have to testify at commitment hearings to involuntarily hospitalize patients who have demonstrated they are dangerous to themselves and others. The judge, attorneys, and the patient and I conduct these hearings in a cramped room where the tension is palpable. Most often I’m preoccupied about my personal safety more than compassion for someone who might lunge across the table in a raging quest for revenge if the judge rules the wrong way.

And then there are the relatively rare encounters with patients who lie to doctors, such as those with factitious disorder or malingerers. I’ve seen them often. Compassion is difficult to muster in these situations as well.

All of these scenarios make doctors, young and old, feel like they’re clashing with dragons. The dragons are out there in the guise of exams and all night calls with no sleep, tyrannical attending physicians or, more often, in our own minds. Our training system is more like a series of trials by fire, seemingly endless quests to slay dragons we find in the world and in our hearts. In the long run, we’re lucky to have any room for compassion left in our souls. It looks like there are many challenges to overcome in our health care system and within ourselves to clear the path for compassion.

We’re more than the juice squeezed from glands and subcortical brain tissues, though. Paladins rode out to the countryside and marched into the forests looking for dragons because they wanted to save the villages , after all. For them, the path to compassionate action was through courage, which is doing the right thing in spite of fear.



  1. I often wonder about this and even more now that the pressures grow. One needs a strong mission and stronger self-soothing skills, not easy to acquire, and as you know not every M.D. does. A hard life. Thank you all.


  2. I think you make an interesting point. I certainly believe that there are many situations in the psychiatric sector in which anxiety and stress overrule compassion. I have been hospitalized multiple times, and I do remember often being treated with indifference, disdain, or, by the younger doctors and nurses, with fear and apprehension. None of that gives a patient a pleasant feeling… It is understandable however. How much support is there for the people who work in a stressful field such as psychiatry? I think that paying more attention to the emotional state of the ones on the other side of the table (especially students and interns) would be beneficial for both the patients and the doctors.


    • Thanks. I think there is support for mental health care professionals, though not all of it is formal. Informal supportive and mentoring relationships are critically important in the education of psychiatrists. As you suggest, this tends to promote more capacity for empathy. Interestingly, there’s also some evidence that the more power someone has, the less empathic he or she might be.


      J. Amos, MD


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