Cynicism is Essential to Medical Practice

It's just one more tool in the doctor's 'black bag'

Photo by Mateo Hernandez Reyes on Unsplash

You have to earn your cynicism. That's my rule. Young pre-med and medical students, even some residents don't have the same right to cyncism as the rest of us who have labored in emergency departments, clinics or surgery suits for years or decades. The same goes for nurses fresh on the job from training and unit secretaries who so recently were high-school kids.

It always troubles me when these people start working in our hospitals and offices and within a week are making snarky, toxic remarks about how stupid the patients can be, how ridiculous their complaints, how pointless their questions and how annoying their phone calls. I agree. All of those things are sometimes true. But the ‘newbies’ don't get to say it yet.

I find it worrisome when they do this too much, even in the first couple of years. And yes, I know that they're working with the same people as I am. I know that drug-seekers abound, that people lie, that all too many of our patients take no responsibility for their illnesses, actions or life-choices. It's maddening. Yes, there is entitlement, neglect and addiction. But we have to encourage our younger, or simply newer, colleagues and co-workers to take a breath and count to ten; ten seconds, ten minutes, ten months, or even ten years if necessary.

The reason I feel this way is that cynicism is a tool. And like a chain-saw or hammer, it requires education. It is sometimes misused, but it is ultimately the mouthy half-brother of skepticism. And we all understand the value of skepticism. It makes us raise our eye-brows before refilling the prescription for a controlled substance that the neighbor stole or the dog tragically ate. Skepticism, even cynicism, makes us look twice at the child's fracture and wonder if it was abuse. Cynicism and skepticism cause us to wonder if perhaps that industry sponsored study isn't especially useful.

Cynicism gets a bad name because in our modern era we associate it with judgment or intolerance. And these days, 'who am I to judge?' is the rallying cry of a dying civilization...certainly a gasping health care system. Despite the warm, fuzzy, well-meaning mantra that everyone has their own truth, we can’t function that way. Judgement, or maybe more properly discernment, are critical to our work. And cynicism goes hand-in-hand with them.

As such, the tool cynicism must be honed. It must be wielded by an experienced worker who understands is uses and its dangers. Cynicism is dangerous unless one has a large enough number of experiences. Medicine is learned through ever larger denominators; the more we see, the better we are. Students and new workers in emergency care have to learn that sick people may be crazy, but crazy people also get sick. They have to understand that even the most frustrating homeless schizophrenic may have a ruptured aneurysm, or something as simple as an eye going dark from glaucoma. And even the most venerable community leader may abuse her spouse at home.

Cynicism is rather necessary to an honest, open-minded view of the world. It is the rifle scope that allows us to know what to tune out and what we must see clearly to hit the target of truth. Without it everything is equally valid, everyone is equally honest, every tale equally true, every person equally ill. While that sort of reasoning might satisfy administrators and the keepers of patient satisfaction scores, as well as an entire generation of painfully sensitive amateur and professional social scientists, it is impossible and woefully dangerous.

Cynicism requires an apprenticeship. We see it, don't we? Young doctors taken in hand by older doctors. Young nurses by seasoned nurses. And if not, they should be. We should have no compunction about stopping someone and reminding them, 'yes, he does seem crazy and whiny. But make sure he doesn't actually have an MI.' Those of us long in the tooth, grey in the beard, have a valuable resource. We have our vast, shared archive of experience. We have all seen the 18-year-old heart attack. We have all met the innocent looking woman with the hidden knife. The professor with the cocaine habit. The sweet grandmother who appeared to have a stroke, but actually drinks whisky like Gator-Ade.

We know, too, the pain of misses. The tragic outcomes born of cavalier dismissal of complaints and the equally tragic consequences of believing everyone is telling the truth. These are stories we have to share as we train our apprentices, as we slowly, carefully put cynicism in their own hands for the right uses. But never, ever at first.

Further, we do medicine and its future practitioners, a disservice when we too easily welcome them into our cynicism as young students. We have to temper our opinions and hold our tongues; or if we do not, we must qualify everything by saying, 'it's hard to tell sometimes. People aren't always what they seem, for good or bad. Be cautious.'

But it's important for another reason. Cynicism is necessary for love and compassion. If we simply believe everything we are told by everyone, if we give equal gravity to every story and every complaint, then we really do not love well. Cynicism, for a parent, is essential to raising children wisely and guiding them in truth. And for the physician, for the nurse, the paramedic, it helps us to see past the surface to the real problem, the real issue. It isn't the fall, it's the abuse. It isn't the chest pain, it's the suicidal depression It isn't the anxiety, it's the pulmonary embolism. It isn't the back pain, it's the pending court date.

Finally, while it sometimes seems that we develop more compassion over time, what may happen is simply that we learn how to save it, to ration it, for the best and most necessary times. I cannot muster compassion as easily for the person whose actions, over years of repetitive abuse of his or her body, and noncompliance in care, result in sickness and trouble. I have difficulty being compassionate for the malingerer who only wants another work excuse and another shot at disability. I have to reserve it for those whose problems are life changing, life shattering or simply painful and scary. For the sick child, the worried mom, the dying husband or wife. If I try to shower compassion, free of cynicism, on everyone I see, then it will be a mere sprinkling, not an immersion. My well will run dry and my patients may suffer.

So dear friends, students, co-workers, don't shun cynicism. It is absolutely essential. But before you embrace it, wait and look and see. Fill your archives with stories. And fill your hearts with love.

Then, you can tell me about those nutty patients (or staff) who drive you crazy. Because by then you'll even care about them. Just a little more wisely. And that sort of love, without any delusion about the one loved, is a goal worth achieving.