Appendix 39a - Cognitive Reframing

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

We pledge not to treat students this way when we're residents, but didn't they all once think that? What happened? How do we treat our patients now?

From an article in Academic Medicine:

We came to realize that the pattern of trauma victims becoming abusers is not something that happens only to victims of incest and sexual assault; it is part of a deep-seated, perfectly normal, and, indeed, usually adaptive human process by which we repress unpleasant experiences so that we can get on with the work at hand.[416]

Conspiracy of Silence

Medical sociology chair Frederick W. Hafferty:

An almost endless number of ethnographies of medical training have pointed out the extent to which the process of medical education involves a shroud of 'mutual concealment' and a generalized 'conspiracy of silence....' One of the most remarkable patterns observed is denial or some form of amnesia about the suffering experienced during internship and residency, as well as its consequences.[417]

Chapter entitled "Life on the Wards" in Medicine as a Human Experience:

I am a medical student - that is my area of expertise. I may not have extensive experience of medicine, but I have spent 4 years watching medical care, and I know there is madness in this system. The irony is profound - we are here in medical school learning to take care of patients, and yet far too often we graduate having learned nothing of caring.... Medical education has a dark side, one that is painful and sometimes tragically deforming to young spirits. I know this and so does every medical student who is really honest.[418]

I did do that says my memory. I could not have done that, says my pride. Finally my memory gives in - Friedrich Nietzsche

"FORGETFULNESS, n. A gift of God bestowed upon doctors in compensation for their destitution of conscience" - The Devil's Dictionary, 1911.


Events once experienced as 'traumatic' are forgotten entirely or recalled with 'sophisticated' bemusement over how naive one 'used to be.' The redefinition of past events or states-of-being is a fundamental part of any socialization experience and thus it is not unusual for students to report one set of reactions on the day of an event (e.g., dissecting their cadaver's face) only to recall an entirely different (and usually more benign) version of events a few weeks later. In these circumstances, the issue is not that they are Iying or participating in some form of cover- up. Rather, they are displaying evidence of 'social amnesia' as they learn to 'not-see' right from the earliest stages of their medical school training.

"Cognitive reframing" is thought to be responsible for the radical change in perspective. It seems to be a built-in way our body handles trauma. Cognitive reframing, for example, is what allows women who have had children to overlook the most excruciating parts of labor and delivery in order to get pregnant again. Some people are better at it than others. One doctor interviewed nearly five years out of internship says that when she reminisces with colleagues, she gets heart palpitations and sweaty palms, and, "all the horrible feelings come rushing back."[419]


[416] Hundert, EM. Academic Medicine 71(1996):624-640.

[417] Light, DW. Journal of Health and Social Behavior 29(1988):307-322.

[418] Medicine as a Human Experience Ed., DE and DH Rosen. Baltimore: U. Park Press, 1984:1-19.

[419] James, D. "Deep Impact." New Physician 48(1999):16-25.

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