Learning Empathy From the Dead

The first-year dissection is often an experience that teaches medical students to emotionally detach from their patients. By forcing future doctors to learn about the lives of their cadavers, some medical schools are trying to reverse the effect.

Charles Dharapak / AP

On a Thursday afternoon in August 2008, Joe Thurman was sitting at the National Cowboy and Western Heritage museum in Oklahoma City, wearing his best suit and staring anxiously at the three empty chairs across from him.

It was the end of a week-long orientation for Thurman, a first-year medical student at the University of Oklahoma College of Medicine. Seated at the table around him were the new classmates with whom he would share a cadaver during first-year Gross Anatomy lab. For most of the students at the table, the dissection, set to begin five weeks later, would be their first experience with the visceral textures of the human body. For example, tearing through fascia, the thin layers of tissue covering the muscles and internal organs, isn’t always easy. To tug off the top of someone’s skull (it’s supposed to sound like ripping Velcro), you’ll need a bone saw and a bit of force.

But before the students experienced any of this, they would have to share a meal with the three people who would soon occupy those empty chairs: the relatives of the woman they would disassemble.

“That was the only thing tempering our excitement about medical school,” Thurman later told me. “You have no idea how this will go. You’re sitting there wondering, ‘How am I supposed to talk to these people?’”

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Most physicians could list the benefits of getting to know the people they treat. Not everyone will walk into an exam room and open up with complete transparency; in some cases, an accurate diagnosis can depend on a physician’s ability to engage with his or her patients.

In highly emotional situations, though, some doctors can find it hard to do so. Physicians have “taught themselves to see this distress and ignore it,” says Jerry Vannatta, the former executive dean of OU College of Medicine. “They know it’s there, but instead of engaging in the distress, saying, ‘My goodnes­s, you look sad, tell me about that,’ they ignore it and say, ‘So how’s the chemo going? You getting the radiation? Any nausea?’” Now a professor of medicine at the university, Vannatta researches and teaches a course on narrative medicine, an emerging field that uses storytelling and literature to help physicians learn to better relate to their patients.

A group of students work on a cadaver in the gross anatomy lab at the medical school at Indiana University Northwest in Gary, Indiana. (Stacy Thacker / AP)

He’s also the founder of the Donor Luncheon, as it’s called. The meal is the first lesson students receive at OU College of Medicine. Vannatta got the idea for the program in 2000, while in Taiwan to teach a workshop on American medical-education practices. He asked the workshop attendees, faculty from 10 Taiwanese medical schools, to each tell him about something unique to their respective institutions. A physician from Tzu Chi University College of Medicine told him that his school has recently implemented a program to remove the cultural stigma of disturbing the dead: The families of anatomical donors were invited to join the students in a Buddhist prayer ceremony before dissections began, and the school had built a hall of honor to display the cremated remains of previous donors, now referred to as “honorable teachers.”

Vannatta immediately recognized the potential. “I said, ‘You bring your students in? These students who are going to dissect that body, and they meet with the family?’” he told me. “‘That’s one of the most brilliant ideas I’ve ever heard!’” He organized the first Donor Luncheon for the following academic year.

His initial hope for the Donor Luncheon, Vannatta said, was that it might equip the students to better cope with the dissection, which can be a traumatic experience. “To walk into a room and start cutting up a human being’s body, it’s not normal,” he said.

The natural response, he explained, is to find some way to deflect the strangeness of the situation—a need that often manifests itself as gallows humor. Students may invent stories about their cadaver or perform what Vannatta called “cadaver tricks,” in which the bodies will be objectified for comedic effect. A group of students might open the tank holding their cadaver and find the body wearing a bow tie, for example, or a student might enter the lab for a late-night study session and see his cadaver propped up and staring at him. In 2013, a University of Pennsylvania study examined what is perhaps the most common coping mechanism seen in the lab: cadaver naming. Two-thirds of the medical students surveyed (1,152 from 12 different medical schools) gave their cadavers nicknames, many of them unflattering references to a specific bodily feature. A particularly wrinkly donor, for example, was named “A Wrinkle in Time,” a donor with an abnormally large heart was “The Tin Man,” and a donor who died of respiratory failure was known as “Wheezy.”

“Inventive naming,” the study authors wrote, “allows students to acknowledge the cadaver’s personhood, while psychologically shielding themselves enough to be comfortable with the dissection.”

But Vannatta stressed that this “inventive naming,” like other unchecked coping mechanisms, can have implications for clinical practice later on. “Instead of referring to Mr. Jones in room 306,” Vannatta said, a physician might say, “‘Let’s go see the terminal in 306. Let’s go see the lung,’ referring to the patient as their sick organ. ‘The liver.’ ‘The yellow man.’” Before they’ve ever walked into an exam room, young physicians have already learned from the dissection that a little bit of comfort can be gained by putting space between the body and the human identity.

The Donor Luncheon, he said, provided a chance to close that gap, “to make it crystal-clear in [students’] minds that this was a person who lived a life—was a father, was an uncle, was an aunt, was a grandmother, was an engineer, an architect.” He added, “It’s changed the whole atmosphere of the Gross Anatomy experience in our medical school.”

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Cadaver dissections usually begin with three simple cuts: a horizontal cut from shoulder to shoulder, a vertical cut following the spine, and another horizontal cut above the tailbone. The skin of the back should peel away relatively easily, exposing a gelatinous layer of fat. If the skin doesn't lift, another smaller incision can create a sort of buttonhole, allowing a finger to hook and tug. When a student finishes removing (or "picking") the fat and cutting through the thin layers of fascia, the muscles of the human back are revealed.

Technically, these first cuts are among the simplest a student will make. Emotionally, they're often the most grueling.

Thurman, now in his third year of surgery residency at a hospital in North Carolina, remembers the first time his Gross Anatomy group opened the doors of the stainless-steel tank, roughly the size of a casket, that held their cadaver. The tank doors hinged open from both sides to reveal the body wrapped in formaldehyde-soaked sheets; they had to turn a crank to raise her to a workable height, and then peel back the layers.

Seven years later, he can still recall the discomfort of the moment: “She’s just this frail little woman,” he said, “and we’re about to take her skin off.”

Her face, after preservation, only vaguely resembled the family photos he’d seen at the luncheon, and the students immediately covered it back up. They also covered her hands, which were wrinkled with bright-pink fingernail polish—the most human thing about her, Thurman recalled. (It's not uncommon in labs for a cadaver to lay splayed open at the chest while the face and hands are kept conservatively wrapped.)

The woman was laying supine, face upward, and to begin cutting her back, they needed her in a prone position. But dead bodies are heavy and awkward, and most of the students had never touched one before. They discussed the most efficient way to flip her. “You’re trying to be as delicate as you would be with your own grandmother,” Thurman said. “But there’s really nothing graceful about it.” Finally, the students moved to her hips and shoulders, one at her head, one at her feet. They counted to three and lifted.

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In the early 1900s, medical schools in the U.S. bore little resemblance to what we know as medical school today. For-profit institutions frequently admitted students who had never finished high school, educated them for a single year, and granted them their license with their degree upon graduation. In 1908, in an attempt to raise educational standards and stem the flow of unqualified doctors, the American Medical Association hired the education reformer Abraham Flexner to tour and evaluate each of the country’s 155 medical schools. Two years later, Flexner published his findings as Medical Education in the United States and Canada, a 363-page report detailing, with acid verve, the shortcomings of American medical education. “The deans ... occasionally know more about modern advertising than about modern medical teaching,” he wrote. “They may be uncertain about the relation of the clinical laboratory to bedside instruction; but they have calculated to a nicety which ‘medium’ brings the largest ‘return.’” The proliferation of doctors was “something worse than waste,” he lamented. “For the superfluous doctor is usually a poor doctor … [T]here is no need to make poor doctors, still less to make too many of them.”

Flexner’s disapproval came through most clearly, though, when he addressed medical schools’ failure to adopt recent advancements in laboratory science. Old treatments like bloodletting had fallen out of favor among physicians in the mid-1800s, Flexner noted, and “medicine, hitherto empirical, was beginning to develop a scientific basis and method”—but even so, schools had been frustratingly slow to respond to changes in the field. “The stethoscope had been in use for over 30 years before … its first mention in the catalogue of the Harvard Medical School in 1868-9,” he reported. “The microscope is first mentioned the following year.”

To make the study of medicine both more rigorous and more exclusive, Flexner called for a “uniformly arduous and expensive medical education.” State licensing boards and medical schools were quick to agree, and the reform that followed was the largest in the history of U.S. medical education: Admissions requirements became tougher. Tuition costs rose dramatically. Curriculums were updated to reflect the new scientific standards of the day.

In the decades after the reform, though, medical educators began to notice a change in their students. In the 1950s, the sociologist Robert Merton led a team of researchers at Columbia University’s Bureau of Applied Social Research (BASR) in a large-scale study of the “professional socialization” of medical students, or the ways in which their professional values and behavior were shaped by their training.

The results of the study were unambiguous: Hospitals, the sociologists said, promoted a distinctly sterile and un-empathic culture. And medical school, they argued, implicitly trained students to thrive in this environment.

Students and doctors attend a ceremony in the gross anatomy lab honoring those who donated their bodies to science at the Indiana University Northwest medical school. (Stacy Thacker / AP)

Among the members of Merton’s team was the Columbia sociologist Renee Claire Fox, who gathered qualitative data as the chief observer at Cornell University Medical College, the site of the study’s most extensive field research. Based on student diary entries and interviews, Fox later wrote in her autobiography, she developed the concept of “attitude-learning sequences,” events that had a “strong emotional, symbolic, and rite-of-passage impact on students.”

Cadaver dissection is the earliest event associated with the attitude-learning sequences Fox identified (other events included taking a patient’s history for the first time, assisting in the birth of a baby, and witnessing a patient death). In the anatomy lab, “students were introduced simultaneously to the cadaver, death, nudity, and anonymity, and to both the obligation and prerogative to cut and explore the human body,” she wrote in an essay summarizing her findings. The first glimpse of a naked cadaver is emotional, the students had confessed; the first cut, even more so. Students were taught to approach the dissection with an attitude Fox labeled “detached concern,” in which they were expected to regard patients with a balance of empathy and clinical objectivity.

However, Fox also found that teaching hospitals ultimately exhibited “more detached than concerned care.” Stoicism became the litmus test for professionalism, and students began to welcome their “greater composure,” Fox said, as a sign of “progression in achieving the professional detachment” they needed to develop as doctors. But, slowly, their feelings began to change. The students in Fox’s study began to report an uneasiness that they were becoming callous or blasé. One student wrote, “We find ourselves not taking as personal an attitude [with the body]. For example, not thinking and feeling, ‘Here is a person who was living and is now dead’ to the extent that we once would have.”

Fox’s findings sparked a wave of academic scrutiny of the effects of cadaver dissection and the consequences of detached concern. In the 1970s, through qualitative methods similar to Fox’s, the medical sociologist Frederic Hafferty conducted a series of studies on the “emotional socialization” of medical students, concluding that the anatomy lab was “a unique emotional test” where students learned “maladaptive coping strategies in clinical settings.” Later, a 1990 Stanford University study by the psychiatrist Peter Finkelstein and the anatomy professor Lawrence Mathers found that student reactions to dissection “bore a striking resemblance to post-traumatic stress disorder.”

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According to a 2013 Mayo Clinic study, 96 percent of American medical-school anatomy programs hold some type of post-dissection ceremony, most of them formal and student-led, to commemorate the anatomical donors and help students process their emotions surrounding the dissection. A student might recite a poem written for their donor, for example, or read a diary entry written after a poignant experience in the lab. Speeches are common, as are portraits of the donors. If the program is among the small fraction that invites donor families to the service, a meet-and-greet will often follow.

Lawrence Rizzolo, a director of medical studies at the Yale School of Medicine, stressed the importance of Yale’s Service of Gratitude, as it’s formally known. It’s crucial, he said, for the students to “feel they have a place and a community in which they can express themselves, and develop their understanding of their emotional response.” He also emphasized that these “one-time events”—memorial services and donor luncheons alike—aren’t enough on their own: In cultivating empathy, it’s also important that students feel they’re allowed to express emotions throughout their learning. It’s the instructors’ responsibility, he said, to demonstrate that emotions have a place in medicine.

“Medical-school training works very hard to beat humanity out of you,” he said, a phenomenon that can’t just be attributed to the demands placed on students. Equally to blame, he believes, is what educators now call a “hidden curriculum,” the set of values tacitly instilled in students by their environment (analogous to the implicit learning identified by Fox). A 2001 Academic Medicine article argued that while medical schools may include lessons on things like listening skills and fostering trust, tacitly, students are learning to value “objectivity, detachment, wariness, and distrust of emotions.” Or, as Rizzolo described the attitude to me: “Buck up, you’re going to be a doctor and you’ll see worse than this.”

Instead of suppressing emotions, Rizzolo said, students should learn to manage them—and emotions can’t be managed if they aren’t acknowledged at all. Once, while demonstrating a dissection of the vagina, a particularly difficult dissection both technically and emotionally, one of Rizzolo’s students gasped. Instead of simply asking if the student was okay—“Everyone’s going to say [they’re okay] because no one wants to be perceived as weak,” Rizzolo noted—he stopped the dissection and remarked at how troubling it was that the previous cuts so closely resembled female circumcision. When one student hadn’t heard of female circumcision, Rizzolo engaged the group in a discussion about it before continuing his demonstration. “Don’t just forge ahead,” he said. “By recognizing [the emotional difficulty], we can allay people’s anxieties.” He added, “I expect my instructors to do that. To pay attention. Notice what’s going on with their students.”

When students have an emotional moment, he advises his colleagues, just give them the time and the space to express it. Break the barrier. Don’t let students hide their trauma from their instructor. But this approach, he added, isn’t a quick fix: Creating a more empathetic profession is something that requires a long-term solution, one that requires professors to exhibit the values they wish to cultivate in their students. “Cultures change very slowly,” he said.

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When his donor’s family—a nephew, a niece, and the niece’s daughter—arrived at the Cowboy and Western Heritage Museum back in 2008, the conversation started out easier than he had expected, Thurman recalled.

The niece, who had been the woman’s primary caretaker, pulled out a picture frame containing a series of faded photos from her aunt’s life. She stood alone in some; in others, she posed with members of her family. Passing the frame around the table to the students, the niece launched into her deceased aunt’s life story: She was born in Eastern Europe during the 1920s. As a child, she fled the Nazis with her grandmother and escaped to the United States, first to New York City, then to California. She could do a handstand at age 70. Her mind never went. She sneaked cigarettes in the bathroom until the end.

Lunch was served sometime during the story and empty plates were cleared before the family finished their biography. When the story caught up with the present—ending with the donor willing her body to OU College of Medicine—the students sat for a moment in silence. “It was humbling,” Thurman recalled, “to think she was our first teacher.”