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Monday, September 15, 2014

Why Is Residency So Harmful? (And What Can We Do About It?)

Genmedmom here.

I'd like to thank "J the intern" for her post on physician depression and suicide on 9/9/14, as it prompted me to read Pranay Sinha's excellent New York Times Op-Ed piece "Why Do Doctors Commit Suicide?" He discusses what may have contributed to two recent intern suicides, namely, the shock of graduating from well-supported medical student to overburdened resident drowning in the macho medical culture. He describes his early intern year as "marked by severe fatigue, numerous clinical errors [], a constant and haunting fear of hurting my patients, and an inescapable sense of inadequacy."

Ah, yes. Residency.

In the comments to J the intern's post, OMDG brings up as additional factor to consider: "the elephant in the room... sometimes doctors treat each other like garbage".

Yup, I agree with that one, too. No one is more cruel to the suffering than the suffering. Many of my own emotional injury during training was at the hands of my colleagues. But, I know that I lashed out as well. We all hurt each other. I'd like to expound on that, if I may.

I well remember being humiliated on rounds, Monday-morning quarterbacked by someone fresh and showered. I cringe as I recall snapping at my intern for waking me up to check on a patient she was worried about. I'd been snapped at in a similar way as an intern. I remember with sinking stomach the disdain and sarcasm I received when I tried to teach a medical student a very simple procedure, and then couldn't do it myself. I still get angry when I think about the patients who suffered as my residents tried to teach me paracentesis, central line insertions, lumbar puncture- and failed on their attempts. I know my anger showed then. When our colleagues rotating at a small outside hospital transferred a sick patient to us in the emergency room, and it turned out to be a case of lab error, no pathology, there was derision all-around: "They dropped us a turkey, guys." When I was worried about a sick patient and called for an ICU consult, the ICU resident came, and told me I could handle it. "Don't be a wuss. Be a real doctor."

The cruelty towards women was pervasive. A pregnant resident had an early miscarriage. Still bleeding, she asked to be excused from her outpatient clinic. The chief, a woman, said no. "Just think of it like your period," she said.

A colleague went out on maternity leave six weeks early, for premature labor. Another resident was pulled from an outpatient elective to cover the rest of her rotation on the floors. The resident who was pulled was very resentful, angry to tears. "Why the f-- would anyone want to have a baby during residency? Why?" Another answered, "I'll never understand it. It's so selfish."

It's well-known that medical training erodes empathy. It took years for me to recover from residency, to feel like I could even begin to take care of people again. Literally. I did a research fellowship for three years, in large part because I couldn't imagine returning to clinical practice.

But, why did I feel this way, when my residency program was well- regarded, with many opportunities to share, reflect, even write? Why were so many of us injured and angered by our experience? So many of us recall their training with a shudder, vowing "I wouldn't revisit those years for all the money in the world."

That's just not right. How can we change it?

Open discussions confronting the cruelty of medical training may help. As a medical student, I was rotating on surgery. A rural hospital transferred a very sick patient to us, someone who had been misdiagnosed and suffered greatly. As the case was reported on rounds, there was loud derision and disgust expressed towards the rural docs. But one senior surgeon, someone so intimidating and revered that just a movement of his hand silenced the crowd, quietly admonished:

"There's no point in criticizing. Your fellow physician took the same oath you did. Assume that they tried, and that they feel terribly. We have all made mistakes, and we will all make many more. Don't waste your time on judgment."

End of that discussion, and it made an impression on me. Don't waste your time on judgment. I think, as teachers, we need to stand up and say that, and live that. Be real doctors.

We also need to dismantle that confusing paradigm of training: You are here to learn, but you should already know how to do it. Sinha also illustrates this in his essay. You were a coddled student in June, and then the doctor in July. You feel like you're supposed to know it all, because everyone is acting like they do know it all. Everyone's got a front. To ask for help is to be weak.

I remember very early in training, asking how, exactly, to write a prescription. I'd never written one before.

Oh, the rolling of eyes, the quick snappish explanation. I was so upset, I didn't catch it all. I spied on other people writing prescriptions and copied them. Seriously, how the heck are you supposed to know how to write a prescription if no one's really taught you?

How are you supposed to know how to be a doctor, if no one's really taught you?

I'm interested to hear what others' experiences have been, good and bad, with an eye towards practical suggestions. How do you think medical training be reformed?

11 comments:

  1. I don't have a suggestion unfortunately. But I would like to make the point that the cruelty doesn't always end with training. Attendings can be just as cruel and critical sometimes. All of this is to say that it is not simply a training phenomenon. Rather it is a pervasive and toxic "medical culture" phenomenon. The whole system needs to be reformed.

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  2. Such a good post. I have recently been reliving some of these moments as I prepare to submit a chapter for a book about physician burnout avoidance and self-care that chronicles my own experiences in residency. To spare the details, visit my blog practicebalance.com and see the early posts ("start here")... Basically I started to struggle in residency, thought it was due to stress and burnout, but turned out to have some physical symptoms and got worse. Went down the rabbit hole of diagnosis that lasted months protracted by the barriers we experience to self-care as trainee physicians due to our horrible work schedule). I ended up having a brain tumor. When I had to take time off, I actually got feedback on my evaluations that said I my leave of absence showed I was "not committed to the field". I was losing my vision before my diagnosis but I didn't realize it, and I struggled to perform visual-spatial procedures that involved ultrasound. I got comments on my evals that said I was "hopefully going to learn procedures to become a competent anesthesiologist" but was "way behind my peers in terms of skill and knowledge level". You know what? Once I had the tumor resection, I could do those things just fine.

    Ok, end rant. I have been out in practice now, and I work at the same institution where I trained, where a few of my colleagues made these negative comments. Every once in a while, I cringe to think about it. But it motivates me to write more, to share more stories like that for the younger audience of med students and residents that come through or rotation. I agree that exposing the "hidden curriculum" is where it's at. No one wants to think about it or talk about it, but it needs to be exposed for change to occur.

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  3. Thanks for posting about the elephant in the room. I don't know of any overwhelming ways to change things, but I think role modeling is a start. We just have to challenge each other not to fall into the trap. Hopefully with awareness we can work to change the culture.

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  4. Positive things that have made a difference to me this year: 1) When residents and attendings that I've worked with in the past say hi and talk to me like a person even when I've moved off their service. 2) Yesterday my resident offered to hold the intern pagers so that we could go to intern report. 3) Working with people who offer to pitch in and help when things are slow if they have to be there anyway. 4) Having a system in place where if coverage is necessary for a sick resident, you switch schedules rather than just taking more difficult rotations. 5) Working with people who acknowledge there is a learning curve and who are patient. 6) Working with people who are able to find humor and laugh at some of the things we see. 7) Having a clear idea of what your job is and what needs to be prioritized and what doesn't, and then being given a little time to figure out how best to get it done.

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  5. One of the most interesting aspects of the cruelty of medical training is how universal it is! I have friends all over the world who relate to these issues. Furthermore the haven't changed since the book house of hod was written! I think the only way to change the system is for us to take responsibility for changing it! Every organization manages it's human resources to comply with legal requierments. We need to ensure out contracts include and mandate leave, we need to have relief rotations were all one does is cover sick and unexpected leave so no one has to cover 2-3 people. It's not just about doctor sanity it's also about patient safety! Patients need to demand care from competent rested doctors and not burnt out sleep deprived zombies!

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  6. One of the most interesting aspects of the cruelty of medical training is how universal it is! I have friends all over the world who relate to these issues. Furthermore the haven't changed since the book house of hod was written! I think the only way to change the system is for us to take responsibility for changing it! Every organization manages it's human resources to comply with legal requierments. We need to ensure out contracts include and mandate leave, we need to have relief rotations were all one does is cover sick and unexpected leave so no one has to cover 2-3 people. It's not just about doctor sanity it's also about patient safety! Patients need to demand care from competent rested doctors and not burnt out sleep deprived zombies!

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  7. I definitely learned in residency when and with whom it was ok to ask questions (not often) and when to shut up. Did a lot of self learning in books. I often wondered, "Are they discouraging questions because I'm stupid or are they afraid they won't be able to answer?" Great post.

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  9. Thank you for your personal post about a universal theme in medical training. I recently wrote 2 posts about some of my experiences during training which allowed me to reflect on that challenging time in my life. I too clearly recollect the humiliation I experienced on rounds. I completed my Family Medicine residency over 14 years ago now and often wonder what residents really experience today in comparison.

    One incident I will never forget happened during my Pediatrics rotation. I was in my first trimester of my first pregnancy, and as a result of not getting my flu shot (learned my lesson), became ill with influenza. My baseline morning sickness created a daily challenge, but I was so unwell that I teetered on needing an admission for myself. Despite the warnings to not enter the NICU on the door with even a sniffle, my attending expected me to be there. Facing a night of call, and knowing I had reached my physical limitations, I called my attending with a barely audible voice and said I needed to go home. He was abrupt, dismissive and hung up the phone on me. Through tears I promptly got in touch with my family medicine program director who was not only understanding, but he defended me to the Pediatrician.

    In terms of reforming medical training, one step is that it needs to start at the top with the head of the residency programs. They should be advocates and role models for their residents. I am passionate about physician heath and well-being and believe the culture needs to change during training in order for practicing physicians to recognize their limitations and foster self-care.

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    Replies
    1. Sara - I have had some similar experiences on the resident and attending sides: http://www.practicebalance.com/2014/07/you-never-hear-doctors-say-can-come-in.html

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    2. The culture of not being able to be sick has to go!

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