"When I was a resident, this wellness concept did not even really exist"
March 27, 2017 12:52 PM   Subscribe

On Wednesday, August 17, 2016, at about 5:15 in the morning, Kathryn, one of our fourth-year medical students, ended her life by jumping out of her apartment window.

The statistics on physician suicide are frightening: Physicians are more than twice as likely to kill themselves as nonphysicians (and female physicians three times more likely than their male counterparts). Some 400 doctors commit suicide every year. Young physicians at the beginning of their training are particularly vulnerable: In a recent study, 9.4 percent of fourth-year medical students and interns — as first-year residents are called — reported having suicidal thoughts in the previous two weeks.

The culture of medicine accords low priority to physician mental health [PDF] despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians' seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.
posted by sockermom (62 comments total) 44 users marked this as a favorite
 
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posted by DreamerFi at 1:00 PM on March 27 [2 favorites]


Passed this on to a healthcare thread I talk in. (Not currently in the field, but was previously.)
posted by Samizdata at 1:01 PM on March 27


(and female physicians three times more likely than their male counterparts)
Wait, is that right? Female physicians are three times more likely to commit suicide than male physicians are? Or are they saying that the discrepancy between female physicians and female non-physicians is three times as great as the discrepancy between male physicians and male non-physicians?
posted by ArbitraryAndCapricious at 1:06 PM on March 27 [4 favorites]


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Every time students achieve what looks to the rest of us like a successful milestone — getting into a great college, the medical school of their choice, a residency in a competitive clinical specialty — it is to some of them the opening of another door to a haunted house, behind which lie demons ...

It is so important that any physician understands this, and since that is rare, I am particularly glad that a medical educator does. Grinding wears down gears: we must never forget it.
posted by Countess Elena at 1:08 PM on March 27 [32 favorites]


Wait, is that right? Female physicians are three times more likely to commit suicide than male physicians are? Or are they saying that the discrepancy between female physicians and female non-physicians is three times as great as the discrepancy between male physicians and male non-physicians?

From the linked article:
The estimated relative risk varied from 1.1 to 3.4 in male doctors, and from 2.5 to 5.7 in female doctors, respectively, as compared with the general population, and from 1.5 to 3.8 in males and from 3.7 to 4.5 in females, respectively, as compared with other professionals. The crude suicide mortality rate was about the same in male and female doctors.
posted by Lexica at 1:18 PM on March 27 [8 favorites]


Wait, is that right?

Original review article.

(Jinx)
posted by bonehead at 1:21 PM on March 27 [1 favorite]


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this culture is endemic to my former profession as well (architecture). Shooting from the hip, there are some quick and obvious parallels one can draw:

1. They both are subject to a rigorous academic training process that deprioritizes sleep and comfort in favor of serving the work. There was a common belief in our grad program that "a shower is as good as 8 hours of sleep."

2. They both are perceived from the outside as high-status professions. At least for architecture, this leads to people vastly overestimating your monetary compensation and social status.

3. They are both populated, in the majority, by people who felt "called" to the profession. Again, this has the effect (in my experience) that people deprioritize mental health and a well-rounded life in service of the work they are called to do.

I don't really have any grand thesis on this other than to say that these conditions seem likely to induce "crises of faith" that go to the core of one's self-worth, a problem exacerbated by poor mental health resources and incentives (as stated in TFA). But I will take this moment to say thank you to a professor of mine who accurately diagnosed my crisis and moved both heaven and earth to keep me on the latter.
posted by turbowombat at 1:24 PM on March 27 [66 favorites]


Wow, this is an excellent and meaningful response, I hope other schools follow:

At Icahn School of Medicine, we will significantly enhance mental health and well-being resources for our students. But we have also committed ourselves to a genuine paradigm shift in the way we define performance and achievement. We must minimize the importance of MCAT scores and grade point averages in admissions, pull out of school ranking systems that are neither valid nor holistic, stop pretending that high scores on standardized exams can be equated with clinical or scientific excellence, and take other bold steps to relieve the pressure that we know is contributing at least to distress, if not to mental illness, among our students.
posted by latkes at 1:25 PM on March 27 [19 favorites]


Also, though I have no data on this, access to drugs and heavy boozing seems to be serious issue for many in this field. One doctor, himself an addict, claimed that some 15% of doctors had drug addiction problems.
posted by Postroad at 1:32 PM on March 27 [3 favorites]


Minor point that I'll drop in because Metafilter, as a community, tends to be interested in these sorts of things: those in the suicide prevention community are tending to move away from the verb "commit" related to suicide, and instead use "die by suicide" or refer to "fatal/non fatal suicide attempt". (A lot of articles/opinion pieces related to this have a much more scoldy tone, which I'm intentionally avoiding; most folks just aren't aware, like I wasn't until relatively recently.)
posted by supercres at 1:34 PM on March 27 [94 favorites]


One doctor, himself an addict, claimed that some 15% of doctors had drug addiction problems.

Only?
posted by notsnot at 1:37 PM on March 27 [1 favorite]


supercres, I actually omitted an anecdote because I wasn't sure of that phrasing. I appreciate you posting that. As somebody who's struggling with major depression and anxiety, I personally have found that phrasing helpful. It prompted me to think: you can die of this if you are not properly treated. And if more people think that, then they may damn well seek the treatment, just as they would for anything else that might kill them. (Assuming, of course, that they are covered for it; but leave aside.)
posted by Countess Elena at 1:40 PM on March 27 [26 favorites]


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posted by SisterHavana at 2:00 PM on March 27


There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel pressure to project intellectual, emotional and physical prowess beyond what we truly possess.

Probably difficult for all doctors, but I don't think most women are socialized to be confident enough to take on responsibility for life and death without also acutely feeling the consequences of their decisions at the same time. That's a ridiculous level of responsibility for any lone human to bear, though. It ought to be spread around a team. (Would probably help reduce error rates, too... I don't think that's a new insight, I think lots of people can probably identify the kinds of things that would help [normal working hours, the opportunity for sleep, etc], it all just costs too much. Or, losing doctors is seen as an acceptable cost, if it's seen at all. Wise move by Dr. Slavin, though, I hope it sets an example.)
posted by cotton dress sock at 2:05 PM on March 27 [2 favorites]


I was trying to parse the Medline article to figure out if these were US/NA numbers or if there was some comparison with countries with socialized medicine, for example, Scandinavian physicians. Linked as related articles: Finland (no date range specified; not a noticeable difference between women and men), Norway 1960-89 (only 9 women out of 82 physician suicides, but they don't indicate the percentage of women physicians overall in that period), England and Wales 1979-95 (female doctors at higher risk than female gen. pop., male doctors lower than male gen. pop.).

Unfortunately most of these timeframes include periods when women were far less encouraged to enter the field, so it probably makes the information largely meaningless today. My thesis had been that certain pressures would be relieved under a socialized system, where the education is subsidized or free (if all the more competitive for it) and the salaries fairly normalized, but little would change in the way of the intense stress of personal responsibility. I'm not sure if the workloads and shift lengths are similar in those systems to what students and some specialties are expected to handle in North America.

I wish we had any sort of cultural recognition or lexicon for people who constantly observe and experience trauma as a job responsibility. Those experiences take a toll, they can't not, and generally means living in a perpetual PTSD state with little to no specialized support or recourse. Even the most mundane-seeming of medical fields still intersects with the aftermath of accidents, violence, torture, and disease, and you still have to get through med school and residency and pay off your loans.
posted by Lyn Never at 2:07 PM on March 27 [6 favorites]


Huge issue for all the health care professions, most so for veterinarians. The rate of suicide in the veterinary profession is almost twice that of the dental profession, more than twice that of the human medical profession, and 4 times the rate in the general population. (Stoewen DL, Suicide in veterinary medicine: Let’s talk about it. Can Vet J. 2015 Jan; 56(1): 89–92) In our academic institution in the last 10 years we've lost multiple people. We now have a full-time counselor and are paying much closer attention to student/resident mental health issues. In addition to enduring as much academic stress as their med school counterparts, veterinary students can look forward to graduating with an income-to-debt ratio of somewhere around 1.6:1, while dentists and family practitioners are at about 0.8:1, orthopedic surgeons at 0.2:1. Also, euthanasia, while often a blessed relief from pain and suffering, is pretty rough on the heart...Having to literally kill your patients presents its own set of psychological issues fairly unique in the world of medicine.
posted by SinAesthetic at 2:08 PM on March 27 [61 favorites]


This is a fairly old paper (1996), but I have no reason to believe things have changed. One reason MDs have a higher rate of successful suicide is easy access to fatal amounts of medication and the knowledge of how to use it. Here are the rates for other professions as well as MDs. The top three all have access to fatal medications. Oddly, pharmacists are way down the list, but still 28% higher than average.

What strikes me most about this article is that in the medical profession women are as successful as men at killing themselves. In the larger population, men are over 3 times more successful than women.
posted by Mental Wimp at 2:09 PM on March 27 [5 favorites]


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posted by scaryblackdeath at 2:11 PM on March 27


I come into contact with a large number of doctors in my job, and occasionally will fantasize about what sort of career I might have had if I'd gone into medicine, before remembering just how stressful medical school and residency really is (from numerous second-hand accounts and seeing the medical students and residents at the local teaching hospital), and am pretty glad that I didn't.

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posted by Halloween Jack at 2:21 PM on March 27 [1 favorite]


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posted by limeonaire at 2:27 PM on March 27


Well, I suppose that's all well and good that this one particular medical school learned that its students' welfare is something worth paying attention to. From what I remember, medical school was a fairly supportive environment, intensely social, and relatively protected. The real soul-crushing begins when you get out.

Except for a few and far between weekend retreats run by hippies and new ager types that focus on physician burnout and wellness (attended voluntarily on your own time, paid for out of your own pocket), there is zero concern for sustainable practice in medicine, at least from the people that finance and administer medical systems. In my large practice, which is a non-profit focusing on delivering care to the urban indigent and underserved -- ie all of the employees are non-money grubbing do-gooders -- we have a huge problem with burnout. I insisted on meeting with medical director quarterly just to discuss how overwhelmed I was feeling and finally, I walked into his office one day and said "I'm done, I need some breathing room, here is my FMLA paperwork, I won't be back for 6 weeks." When I returned, somewhat re-focused and rested, there was zero offer for mentoring, counseling, a change of work responsibilities, or anything. In fact, on my return I had asked for a reduction in my FTE status and was told that could not be accommodated. I am the busiest provider in my practice, and have made lists of Seattle Best Doctors several times, and there was no ability to protect me.

Earlier this year, a colleague of mine, a 25 year employee, attempted suicide. She is now on extended leave, I went to go see her and it is doubtful she is coming back. Back at the office, there was no mention of anything. She was just "gone" one day, "We're all going to need to pitch in to cover her, no we don't when she'll be back."

I think it is true that there is a culture of being strong and not sharing personal details in medicine, but I don't think that is what is driving the problem of physician burnout. I think that it's more the financial pressures, the lack of control, and the pervasive sense that we are all in survival mode all the time, operating on the thinnest of profit margins and if we let up at all, so that we can eat dinner with our families or attend a kids' soccer game, then our compensation is at risk, the financial well being of the organization is at risk, that our patients won't get what they need done.

Within the world of health care reform, a frequent notion is the "Triple Aim" -- improving patient experience, improving population health, and reducing costs. The literature around health systems continues to come back to these ideas. For any health care plan to succeed, you need to demonstrate how you are addressing these three aims.

Lately, there has finally been a little pushback and now you see people using the term "Quadruple Aim", with the fourth pillar being improving the work life of health care providers. We have a huge shortage of doctors in this country, especially primary care, and the physicians we have are dropping out of the system quickly. A viable health care system needs to be able to recruit and keep quality providers.

There's a conference coming up in the fall I'll be attending (again, on my own time, at my own cost) where people will be speaking about actual successes they've had in creating sustainability in medicine. Whether I'll find any receptive ears when I get back home, I have no idea.
posted by Slarty Bartfast at 2:28 PM on March 27 [87 favorites]


I wonder how much the "second shift" problem contributes to that higher rate of female physician suicide. Med school and residencies are a horrible grind, but it's generally acknowledged and a lot of space is made for them. I wonder if that space at home may not be being made for female physicians.
posted by corb at 2:33 PM on March 27 [25 favorites]


I've noticed that doctors and nurses, moreso than other professions, act like no rules whatsoever apply to their employment. Reasonable accommodation, anti-discrimination laws, these all barely exist. What they put med school students and residents/fellows through is abominable. And the reasons? Mostly because older generations had to suffer through it. Radical reform is needed. We need more doctors and this military-derived training isn't just bad for patients but rightly scares otherwise qualified people away.
posted by 1adam12 at 2:47 PM on March 27 [35 favorites]


Medical training also tends to occur at a chronologically vulnerable age. The difference between going to medical school in your early 20s versus your early 30s could not be more different. You meet some highly dysfunctional and incredibly malignant personalities in medical training. Having these people in control of your well-being and livelihood has extraordinary impact on your stability. When you are young you simply are not as equipped to handle this. It is so new, so foreign and so toxic that cumulatively, the development of depression is not so much a possibility as a foregone conclusion. Add to this the ridiculous hours, the exposure to human misery and suffering and disease in all of its forms - burned and mangled trauma victims, moaning geriatric husks enduring their final hours in the ICU, incontinence in all its forms and every type of natural and unnatural bodily discharge imaginable. In the ivory tower that I trained in, hostility and dysfunction were rewarded. While I met quite a number of wonderful people, some of the most horrible personalities I ever encountered in my 51 years were in a single three year stretch, all or most just a few years older than myself and still in their own training. Perhaps it is better nowadays. Thinking back it was the only time in my life I was actually suicidal. Not so much actively considering it but moreso many a day where it seemed like a peaceful and inviting alternative to another day on the wards.
posted by docpops at 2:56 PM on March 27 [49 favorites]


American medicine has always embodied the best and worst aspects of America, for me. Both the crass commercialism and the pioneer / Calvinist spirit, all in one. It was a true culture shock.

It doesn't seem like it should be a survivable experience. In a way it's like boot camp, the human is destroyed in order to make the capitalist soldier.

I remember working crazy hours as a medical student and rural intern in Mexico but at least it was fun, somehow, you know? Even the emotional abuse was intended to be self-effacing. But as an intern, as a rookie doctor, you're going to fuck up and people will suffer for your ignorance; that's by design, it's supposed to make you learn. And that's tough for anyone to live with, much less perfectionists that have gone 20, 25 years being the best at everything they attempted, or the bleeding hearts that just want to help.

I went into medicine already having PTSD; it was a few years of additional catastrophic trauma, of watching thousands of people die, before the emotional dam burst. Only two things can squeeze a tear out of me at this point;

1) At any point, and for any reason - recalling the time as an intern I had to deliver a non-viable 22 week baby and the screams of the mother with each contraction, knowing that her baby wasn't going to survive once her labor was finally over. My senior resident and my attending both knew this labor was going on and knew I was there alone and just decided not to pick up the phone. Twenty years later I can still hear her.

2) Watching a close family member's reaction to "the talk" after a code went the other way. When they start to lose it, I start to lose it.

I think Pamela Wibble has a lot of work written on this topic. There's just an endless sea of trauma of the heaviest, most unspeakable nature that we in medicine just float on, and try to cling to the raft of whatever vestiges remain of our humanity. We get stockholmed into this shit when it's way too late to get out. And we all know we'll get railroaded out if we say word one.

Part of what keeps me going on my 100 hour work-week is the knowledge that for a lot of my patients, there is no safety net. Either they address this issue through my office; or on this hospitalization; or I never see them again unless their family splurged for an obituary.
posted by hobo gitano de queretaro at 3:39 PM on March 27 [48 favorites]


3. They are both populated, in the majority, by people who felt "called" to the profession.

Not a doctor, never wanted to be, but some of the pre-med classmates I talked to were "pushed" towards medicine by their parents. They came from high-pressure, high-achieving family cultures that seemed to have zero time for emotional safety. My partner is not a doctor either but comes from the same culture. Holy shit, that kind of trauma just never heals.
posted by klanawa at 3:51 PM on March 27 [11 favorites]


Not a doctor, never wanted to be, but some of the pre-med classmates I talked to were "pushed" towards medicine by their parents. They came from high-pressure, high-achieving family cultures that seemed to have zero time for emotional safety.
My sense is that's true. But nurses also have a much higher suicide rate than the general population (if you control for gender), and I think they're less likely to come from that kind of family.
posted by ArbitraryAndCapricious at 4:05 PM on March 27 [5 favorites]


At Icahn School of Medicine, we will significantly enhance mental health and well-being resources for our students. But we have also committed ourselves to a genuine paradigm shift in the way we define performance and achievement. We must minimize the importance of MCAT scores and grade point averages in admissions, pull out of school ranking systems that are neither valid nor holistic, stop pretending that high scores on standardized exams can be equated with clinical or scientific excellence, and take other bold steps to relieve the pressure that we know is contributing at least to distress, if not to mental illness, among our students.

Serious question - if you're de-emphasizing grades and MCAT scores what do you use to evaluate applicants instead? The idea of "let people in by lottery and see if they're any good at it" seems legitimate but I dunno if that has a positive effect on the pressure students feel once they're there...
posted by atoxyl at 4:11 PM on March 27 [3 favorites]


Serious question - if you're de-emphasizing grades and MCAT scores what do you use to evaluate applicants instead? The idea of "let people in by lottery and see if they're any good at it" seems legitimate but I dunno if that has a positive effect on the pressure students feel once they're there...

They didn't say do away with entirely, they said "minimize" which probably means some form of "include as part of a holistic review but do not base entire decisions on."

For those who haven't had the pleasure/headache/misery of writing a medical school application, grades and standardized test scores are a small fraction of a personal dossier that also includes multiple essays (many schools request additional essays personalized to their prompts after the first round of reviews they cash your application fee check), 5+ letters of recommendation, and a resume with a brief essay written for each of your "most meaningful" activities. This is to say nothing of the interview days, which now often involve role play scenarios and multiple rapid fire interviews (like speed dating).

Which is all to say that there is a lot that goes into medical school admissions besides the GPA and MCAT already. It's unclear to me that any of it is better or worse as a tool for improving the mental wellbeing of pre-medical and medical students.
posted by telegraph at 4:58 PM on March 27 [5 favorites]


Thank you to the doctors who are sharing their experiences here.
posted by latkes at 5:10 PM on March 27 [17 favorites]


It's unclear to me that any of it is better or worse as a tool for improving the mental wellbeing of pre-medical and medical students.
Yeah, in some ways I think it makes the process worse. Not only do you need to have stellar grades and amazing MCAT scores, but there's an activities arms race that makes students think that they need research publications and patient care experiences that involve actually saving lives and leadership of national organizations and stuff that just isn't realistic for most undergraduates. There's also a kind of solidity to grades and scores: you know what's expected of you. It's a lot harder to figure out how to come across well on an interview day and how to forge relationships with professors that will make them write eloquent letters for you and how to do all the stuff that makes you come across well in a holistic application process. And honestly, my sense is that the holistic thing is kind of bullshit, and students are basically admitted based on their grades and scores, unless they fuck up royally in some other part of the application.

(I'm not a doctor. I am a pre-med advisor.)
posted by ArbitraryAndCapricious at 5:12 PM on March 27 [6 favorites]


When I was in college, I knew a girl who was bursting out all over with screenwriting ideas and a burning desire to be involved in theater tech. But she had drama in more ways than one, and I remember seeing her shepherded around the campus by her stone-faced parents. I heard secondhand that they were dead set on her becoming a doctor.

Not long ago, I thought of her name, and thought to look her up. It turns out she's ... a doctor. I hope she's doing all right.
posted by Countess Elena at 5:16 PM on March 27 [5 favorites]


My personal brush with the impersonal nature of med school this afternoon is that because I didn't click some buttons on a website on Friday, but instead clicked them on Monday (it is both more and less complicated than that, really), I am going to lose points from my overall grade on my last clerkship. And gallingly, those points come from my "professionalism" grade.

One of the things that makes med school so difficult is that we are all working enormously hard, and we are being evaluated by a faceless bureaucracy that seems not to care about our actual interactions with patients, but instead cares about our ability to jump through hoops just for the sake of hoop jumping.

I don't mind that standardized exams contribute to my grades; even when I don't do so well on an exam, I know that it's a reasonable standard, and I have a general sense of how to improve my performance in that regard. But it bothers the hell out of me how much of my grades come down to the arbitrary whims of administrators.
posted by ocherdraco at 5:31 PM on March 27 [12 favorites]


For those who haven't had the pleasure/headache/misery of writing a medical school application, grades and standardized test scores are a small fraction of a personal dossier that also includes multiple essays (many schools request additional essays personalized to their prompts after the first round of reviews they cash your application fee check), 5+ letters of recommendation, and a resume with a brief essay written for each of your "most meaningful" activities. This is to say nothing of the interview days, which now often involve role play scenarios and multiple rapid fire interviews (like speed dating).

I have not - thanks for explaining. I definitely get the same feeling as some of the other people replying that this doesn't feel less stressful than a test - though I buy that as far as designing a fair admissions process goes it's desirable to evaluate candidates from as many angles as you can.
posted by atoxyl at 5:44 PM on March 27


I'm part of my university's premed process, and I will now incorporate the idea of sustainability into my interviewing / advising process. Thanks to everyone here for your input.

I have an undergrad who is participating in funded institutional research into loss of empathy during training and residency.
posted by Dashy at 6:33 PM on March 27 [5 favorites]


Thank you to the doctors who are sharing their experiences here.

Yes, thank you. Please take care of yourselves, too.
posted by MonkeyToes at 6:34 PM on March 27 [9 favorites]


The article says that part of the problem is that the kids who go into medicine are often pushed to be competitive perfectionists starting in middle school. That makes me wonder: Why is medicine so competitive?

There's a chart I remember - I think it showed up on Metafilter at some point - which graphed occupation and income of children versus income of parents. In most cases, average income brackets of children were more-or-less similar to those of their parents. There were a couple of exceptions that stuck in my mind: The average artist had a low income but had high-income parents, and the average doctor had a high income but middle-income parents. Is that something structural that maybe won't go away no matter what medical schools do about their admissions processes? If you have parents who want to launch their children from middle income to high income, won't they push their children to perform and achieve at whatever arbitrary or non-arbitrary measures that medical schools put into place to figure out who to admit? Make mastery of crokinole the admission criteria, and won't parents end up destroying their children's mental health in pursuit of crokinole perfection?

How do you solve that? How do you solve it in a way that still attracts hardworking, dedicated people to the profession?
posted by clawsoon at 6:47 PM on March 27 [4 favorites]


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posted by ThePinkSuperhero at 7:05 PM on March 27


I remember a long argument I had, possibly with someone here on the Blue, about how ludicrous it was to say that doctors, alone of all our species, not only could but should function better on ridiculously long shifts and no sleep. Because although we know, in great detail, what happens to human beings denied sleep and put under severe stress, we deny that reality when it comes to doctors.

It wasn't the first medical person to tell me huffily that long, debilitating shifts are absolutely necessary to proper patient care. And it's still bullshit. Medical errors kill a lot of people, and I would bet you very good money that "attending physician/nurse has not had adequate rest" plays a big part in those episodes.

But yes, if you want to make people kill themselves and develop addictions, by all means use methods akin to torture to make sure they never sleep or feel relaxed or have any kind of normal life, meanwhile also put them in charge of people's medication and medical care because god forbid we let go of our sick Calvinist macho-god ideal of what a doctor is long enough to actually use some goddamn sense.

I remain incredibly angry about this stupidity. God forbid my life depend on the sharp thinking of some poor soul on the back end of a 24-hour shift.
posted by emjaybee at 8:51 PM on March 27 [34 favorites]


Not directly med school related, but when my wife started her clinical psychology grad program, I was struck by how shitty the professors were to each other and their students. I can only imagine what it's like in a field of study that doesn't include an emphasis on mental health.
posted by Big Al 8000 at 8:53 PM on March 27


emjaybee: Fragmentation / non continuity of care remains a critical roadblock to reducing hours in not just the medical profession but in the economy as whole. For any job that requires continuity of knowledge (either a doctor caring for a patient or an engineer designing a solution to a problem), trying to replace one person working 5 days a week with say, two part timers, one doing Mon-Wed and the other doing Thu-Fri, is going to lead to a drastic drop in work performance. Companies that try to cater to part timers usually have to pay for 6 days of work a week (with one day overlap for a handover process) and get something closer to 4 days of usable work, but often that's the only way to get working mothers to maintain their employment. I could see that almost every company, if they could, would want to make their workers do longer shifts rather than hire more workers. It just so happens that hospitals were able to take this to the extreme - working doctors way more than 40 hours a week, due to doctors being willing to do the extra work, and being a profession where "striking" to damage the company in order to demand better conditions isn't really an option.

(Imagine if doctors just let 1000 patients die just to make a point against their employer and force better conditions....)
posted by xdvesper at 9:22 PM on March 27 [4 favorites]


Jesus Fucking Christ this article makes me so angry. So angry that I checked myself before I wrecked myself and checked the date of publication, then found my anger growing anew.

It's not that it's terribly sad, which it is, or that it stirs up a lot of older memories of crummier times, which it does. Or that I've any delusions that Kathryn's death could have been prevented, which I will never know. Rather what drives me apeshit mad is that this is being written now, and not ten or twenty years ago: when we've had two decades' worth of time to mull over the importance of mental health and support services for not just people in medicine or medical school, but for everyone.

What do you expect from people who work their asses off through high school to get into a undergrad, who work their assess off to go to medical school, and work their asses of to get into residency? Many of whom continue to work their asses off more to get into fellowship programs? All of whom were cut down at every milestone of progress, every marker for success: you're at the top of the class in high school? Welcome to college, where everyone is, too. At the top of your class in college? Welcome to medical school, where everyone is, too, etc.

It's like a really fucked up version of Jenga, where you're the tower being built ever higher, and circumstances allow for your inner structure to be poked at and hollowed out, before you just collapse. And the truly fucked up thing about it is that a) you get used to it, b) you may even grow to like it, and c) the only way you learn that you don't like it is through at least having one go at it. At least one failure. Bravo, truly, to those who choose not to continue down this path: the folks who had enough fortitude and insight to realize that medical school was not for them. Most of us didn't. I know I didn't grow up and figure things out until I was neck deep in it, and even then the agent of change was not me but someone else.

These all are tiresome and played-out tropes and often tied into the notion that only the strong survive, and that we should wear our scars with pride. Through adversity to the... what? All this bullshit?

There are indeed many malignant people in medicine, as docpops writes. But it's like things are with bullying: it's not enough to say "you're not alone," or that things will be all right, or that you'll offer support to those being bullied. All the questions raised by this dean are good, but how does anyone begin to address the issues of culture when there are still arguments about work hour limitations, and people, including students and residents, who still think that work hour restrictions are harmful to a good education.

We're still being sold the idea that scars from such suffering should be considered a mark of distinction.

And things arguably only get more difficult once you're practicing, as Slarty Bartfast replies above. I was fortunate enough to have attended a school that had a good enough support system and professors to have seen that I needed help. What about now? I'm surrounded by residents who have crippling student loan debts dating back to undergrad, and colleagues who've chosen to serve an predominantly indigent community. Who are constantly being told, like before, to work harder, not smarter. Or harder and smarter. But not too smartly, lest you anger the capital-B business folks who think they know how to practice medicine without supporting every arm of the healthcare team.

One of the first large student gatherings in med school was led by a physician who told us that practicing medicine is nothing like selling cars. I remember thinking: "well, no shit." These days it's especially laughable to think that he was supporting the notion that we'd entered a noble profession, as if nobility can't be found in any profession or by anyone.

Also, these days medicine is a lot like selling cars: get your numbers better, or no bonus for you. When your bonus isn't really a bonus, but a cut of what was once your salary that's now tied to certain metrics. And if you can't get your numbers better, you may be out of a job, because third prize is you're fired. Such is the way of medicine these days, when so much of it is led by people who aren't clinicians. But that's a long gripe for some other time.
posted by herrdoktor at 9:22 PM on March 27 [24 favorites]


As I read the article and these thoughtful responses, I’m struck thinking about this from the perspective of a resident physician.

In large academic medical centers, residents are the lifeblood. We are first on the scene, we pre-round, round, post-round, write notes, while getting paged and prodded and reminded and encouraged and embarrassed and sometimes praised and then paged again.

Yes, doctors of yore were house officers and lived in dorms. Yes, duty hours have been restricted (although just kidding! the ACGME said). But today we chart electronically with bloated notes. Student debt is stifling and interest accrues by the second. We see higher throughput. My email chimes daily to remind me we’re overflowing and wouldn’t I please discharge some of these patients?

There are scores of other professionals in the hospital who work very hard and this is not to diminish their effort, so much as to convey the at-times exhaustion of residency.

I just submitted my mandated weekly timecard (via a delightfully dreadful software interface). Last week I worked 67.5 hours. I am on a light rotation in a relatively benign specialty. My program prides itself on resident wellness and avoidance of burnout. There is talk of work-life balance. And yet – I was scheduled to work for 25 hours straight through Friday night, which made me tired and cranky and shot the otherwise unencumbered golden weekend. My father asked if I got an extra day off to compensate and I laughed, because that seemed ridiculous.

Why focus on residents when the issue at hand is students? As above, residents are the lifeblood. It’s hard to foster positive medical education when that essential force is ailing. Residents play a middle cog in the system, managing expectations and personalities of attendings while delegating, teaching, and guiding their students. As a student not long ago, there were residents I revered and those I disliked. Fear, anxiety, empathy, and hope for acceptance were also common occurrences. Like others have said, the culture and milieu of the hospital quickly seeps into the new white coat. What is tolerated? What is respected? What is disregarded? We learn from example and there’s no closer role model to students than their ever-present resident. “Just follow me,” he said.

As we seek to change the medical system, there are clearly many avenues to pursue. I hope graduate medical education can be one of them. It’s a sea change in attitude that goes beyond duty hours, beyond pay, and into truly recognizing the person, the humanity, within the medical trainee.

I’m typing into the night and aware of my early alarm clock for tomorrow. Meanwhile, I appreciate the insight, support, and camaraderie in this thread. Thank you.
posted by Mr Yak at 10:32 PM on March 27 [16 favorites]


I have a best friend who is currently in an extremely punishing Master's program at BU, to prepare them to get into medical school. They have a relentless drive, passion, energy, and tenacity that will help get them through school, but the amount of psychological pressure that they are under, combined with the incredible difficulty they are having to secure a therapist is ridiculous, combined with them being a queer person of color. I should probably send them a text...
posted by yueliang at 11:43 PM on March 27 [1 favorite]


I'm a surgeon (in what is generally considered a competitive subspecialty). I've been an attending for a few years and really love my job--I work at a pediatric charity hospital and am in general free from many of the worst aspects of American medicine (I don't have to worry about whether patients have insurance, and my salary is not tied to relatively arbitrary measures of productivity).

I also quite liked medical school (and undergrad, for that matter) & my medical school was fairly supportive/encouraged self care and wellness. Nonetheless, a girl in the year ahead of me died by suicide in the library bathroom, and one of my classmates (also a surgeon though we were not residents together) died by suicide when he was in his first year of fellowship. I didn't know the girl at all but my classmate I knew reasonably well; I was shocked at his death. He had always seemed happy, funny, solid--I know it's a cliche to say how unexpected it was but I found it hard to imagine anyway.

Surgical residency is something else--there were some good moments, of course, and I am grateful for the training that has made me the surgeon I am today--but it was also hard in ways for which I was completely unprepared. I really don't think it's just the hours (though of course that doesn't help)--a lot of it is the unsettling mix of having so little control coupled with so much responsibility. I also found it very difficult to get used to being yelled at (some of the other residents seemed to deal with this much better). No mention was made in my program of concern for our mental health, self care, or anything like that. One of my classmates stayed home once when sick when we were juniors and people were still talking about it when we graduated, for example. I am one of those people who always knew they wanted to be a surgeon (and currently can't imagine doing anything else); even now it is hard to write about/admit to the (sometimes massive) self doubt that is an inevitable part of being a surgical resident.

I don't have any great answers. I do my best with my own residents (I certainly never yell). I do think having a supportive partner makes a huge difference--Mr Moon is a surgeon in the same field (we got together at the end of residency), and being able to understand the demands of the other's job is a huge benefit to us both. I imagine there are fields that help their trainees manage better than we do and I wonder if we can learn from them.
posted by n. moon at 7:31 AM on March 28 [12 favorites]


It seems like this is an area where the sunk cost fallacy runs rampant. If you have spent years and years and hundreds of thousands of dollars to become a doctor, and then you find out that you hate it and doing it is killing you— what options are there? Do you drop out six months before graduation and find a job? Do you go work in a Starbucks, knowing that you will never escape the debt burden?

Every higher-ed discipline is garbage at helping people in advanced degree programs detach from the discipline and find ways to choose other career paths, but it seems especially acute in medicine. So much of the narrative is “the only way to pay off loans is by being a doctor” that the possibility of becoming anything else must seem ludicrous, no matter how destructive remaining in the wrong profession indefinitely obviously is.

Also, so much of it is an identity factor— just as people are terrified to call off a wedding because of the “what will I tell my family and friends” issue, I imagine “how do I tell everyone I’m not going to be a doctor after all” must be an impossible decision to make, especially for driven people whose lives have always been defined by their successes and their goals.

One thing that some people in higher-ed have started doing is telling first year students, from the beginning, that you can leave the program and still have a good career and a quality life. We always hear about people who “wash out” of med school— but what if those people were talked about as possible role models instead of failures? What if those people were brought back to talk about how their decision to leave led to better things? What if those people were treated with the same respect as alumni? Not the ones who actually screwed up/plagiarized/skipped all classes/stole things, but the ones who saw that med school wasn’t going to work out for them and decided to leave. We really need to move past the idea that people who leave unhealthy environments are “quitters” or “losers”. Other disciplines have made some limited progress in reframing this narrative— medicine would do well to learn from them, and do better.
posted by a fiendish thingy at 7:54 AM on March 28 [10 favorites]


I'm a resident in what is generally considered one of the more pleasant, supportive specialties. But man... if this is what life in my specialty is like, I shudder to think what things would have been like in surgery.

I think n. moon really hit it on the head with this:

so little control coupled with so much responsibility

That's exactly it. That's what makes this job so psychologically draining, so dehumanizing.

You spend hour after hour on the wards writing notes, filling out forms, writing more notes, calling subspecialists to please come see the patient that you asked them to see days ago, getting yelled at in response about how busy the subspecialist is, writing even more notes, and knowing that anything you've done or documented incorrectly or incompletely is a possible medical-legal threat to you and your team and your attending staff and the whole hospital. (You'd think this profession would at least be forgiving to those of us with bad handwriting.) You are fighting against a brick wall of institutional inertia at all times, and when something can't get done for one of your patients because of things that are wildly outside your control, it's still you who is answerable for it.

You're expected to be a walking encyclopedia of medicine, ready to explain any physiologic process or medical problem in excruciating detail at the drop of a hat in either plain English or in Medicalese — although woe betide you if a word of one slips into the other — and to offer yourself up cheerfully for endless "pimping", a slang term for aggressive quizzing from a staff doctor or senior resident (there are various urban legends out there about where the term comes from, none very pleasant).

Then, after all the pimping and the note-writing when you actually get to settle down for some medical problem-solving and decision-making, you've come up with a management plan for your patient that your team agrees on — only to have the staff doctor come and shoot it down with no explanation, or a poor explanation that contradicts all your previous teaching, or they'll write extra orders and not tell you about them, or even tell a patient you thought was staying the night that they can go home, lining you up for a lovely call at 9pm from an angry nurse who is in turn being yelled at by an angry patient wondering why you lazy residents haven't completed the discharge yet.

All of this on the background of a 25-hour shift every 4 days, routine 12-hour days the rest of the time, and little to no control over what your schedule looks like.

Residency is often presented in terms of tension between learning and service, the idea being that a program is balancing its responsibility to you (training you to be the physician you've come to train as) with your responsibility to it (admissions, discharges, daily functioning of the wards and clinics, quality improvement projects, research...). The problem isn't just that the second list is considerably longer than the first, and that the learning/service ratio is laughably far off in most residencies. It's that this model considers the program's responsibilities to its residents to end at "learning".

There is no space here to acknowledge that in exchange for the service we offer, we deserve not just learning, but also downtime, internal and external supports, career advising, control over our schedules... programs may offer these, to a limited degree, but they are presented as bonuses rather than basic obligations, because they aren't part of the learning/service dichotomy. But they are part of the control/responsibility dichotomy, which is why I think that's an excellent way of looking at things.
posted by saturday_morning at 8:17 AM on March 28 [26 favorites]


(Very grateful for this thread btw.)
posted by saturday_morning at 8:18 AM on March 28 [2 favorites]


Since there are so many doctors and people in close contact with doctors in this thread, I have to ask while I can. How can you manage to stay awake and functional for so long? Is it a learned skill? Some amount of resilience that you either do or do not have?

I ask, because I realized fairly quickly in my late teens/early twenties that I could only be awake for about 20 hours at the most before my brain would start to shut down, and by the 26 hour mark my body would just give up and join it. If I had been awake that long, only a life-or-death situation would be able to keep me conscious, by sheer dint of adrenaline, and then only long enough to crawl into a somewhat safe corner to pass out again. And this would wreck my health for the next week.

So I have serious respect for anyone who can do it. But just based on my lived experience, every time I read these stories, it's like reading one of those Brothers Grimm fairy tales, where the protagonist has to go through some heavy-duty physical/mental torture to (maybe) reach their happy ending. It just doesn't seem worth it, how can we keep doing this to the people who are supposed to heal us?
posted by sharp pointy objects at 9:30 AM on March 28 [1 favorite]


Since there are so many doctors and people in close contact with doctors in this thread, I have to ask while I can. How can you manage to stay awake and functional for so long? Is it a learned skill? Some amount of resilience that you either do or do not have?

It is a learned skill, yes. Think about college or high school when you had a big important exam. When you have heightened sense of urgency, you can force yourself to pull an all-nighter or at least make it on 3 hours of sleep and be somewhat functional the next day. Yeah, eventually you have to catch up sometime but you learn to push "sometime" back.

Historically, doctors have been trained to operate this way on a continuous basis. Things are a little different now with work hour restrictions, and I cannot speak to that. The trade off we were promised was that once we made it through 5 years (2 years of med school clinical rotations + 3 or 5 or whatever years of residency), things would ease up a bit. Yes, we all would be faced with being on call or having to summon the strength and focus occasionally to put in an overnight or a long week or whatever, and the crazy impossible training of residency is what allowed you to do that.

The problem is that it is a set up for abuse. If I was putting in crazy long weeks because of sick patients, I'd be able do it in a heartbeat (and sometimes I still do). But with rising costs in health care, and an insurance market that does nothing but ratchet down on patient care, my ability to put off self care and sleep is what allows me to continue to work in this dysfunctional system.

Every single physician I know looks at themselves regularly and says, "There is absolutely no way anyone in any other field would put up with this shit." If nothing changes and the way we finance health care continues to get ever more complex and we don't attend to physician well-being, the system will collapse, especially when you have young doctors coming out of training not used to the same kind of demands placed on their souls. For me it can't happen soon enough.
posted by Slarty Bartfast at 11:31 AM on March 28 [4 favorites]


Since there are so many doctors and people in close contact with doctors in this thread, I have to ask while I can. How can you manage to stay awake and functional for so long? Is it a learned skill? Some amount of resilience that you either do or do not have?

It's definitely a learned skill--it gets somewhat more manageable the more you do it. And, I think, it is one benefit of being fairly young when you're in training--there is no way I could now function on the amount of sleep I got as a resident. I also drank a ton of caffeine (rock star, monster, etc). Plus you let a lot of other things go that you would usually do in your free time, and, if you're lucky, your friends and loved ones will understand that you have v little time available.

My experience has been like the trade-off to which Slarty Bartfast alluded--residency was miserable but my work life now is good. I do work long hours but I am basically never up all night, and don't spend an inordinate amount of time on BS. I wish this were true for more doctors.
posted by n. moon at 1:59 PM on March 28


It seems like this is an area where the sunk cost fallacy runs rampant. If you have spent years and years and hundreds of thousands of dollars to become a doctor, and then you find out that you hate it and doing it is killing you— what options are there? Do you drop out six months before graduation and find a job? Do you go work in a Starbucks, knowing that you will never escape the debt burden?

That's not strictly a case of the sunk cost fallacy - the existing loan burden is part of the decision because they are choosing between a lucrative job that will cover payments or not. It'd be a sunk cost fallacy if they had the option to take a lucrative unskilled job that would pay just as much as being a doctor, but chose to work as a doctor because they had done all that work to qualify.
posted by the agents of KAOS at 2:17 PM on March 28 [2 favorites]


This was my best friend - I changed her gender to help protect her anonymity. She never got help and she died this past June. May she rest in peace. http://ask.metafilter.com/198478/Will-my-doctor-friend-lost-his-medical-licence-if-he-checks-into-an-inpatient-mental-facility
posted by hazyjane at 2:34 PM on March 28 [14 favorites]


One of my classmates stayed home once when sick when we were juniors and people were still talking about it when we graduated,

Flames on the side of my face, etc.

This reminds me of terrible places I have worked, where standing up for your rights as an employee, or simply as a human being, caused shock and consternation among everyone else because that was Simply Not Done and usually meant you'd be quitting shortly or be fired. I mean things like saying no, I was not trained in this and it's not safe for me to do it, or no, this is actually not legal for me to do and I'm not going to break the law.

(The boss who yelled at us when we hesitated to use a drill to install shelves in walls we had good reason to think contained asbestos, for example. The boss who flat-out lied to my husband about the hours he was contracted to work then reacted with rage when my husband refused to stay extra. And so on.)

I guess I've never had to worry that me quitting or refusing would mean a sick person would go without treatment, so it's not the same, but on the other hand, I do kind of think doctors need to go on strike. Isn't there a doctor shortage? Seems like if doctors got together they'd have a certain amount of power.

I don't believe that doctors, any more than any other group of people, owe it to the rest of society to be repeatedly harmed for a corporation's profits.

If the push for socialized medicine goes through, I'd hope everyone involved made outlawing overwork/exhaustion/exploitation of medical staff part of the deal. We will also need a whole lot more doctors at that point, so again, it seems like a place where medical professionals had an advantage.
posted by emjaybee at 2:35 PM on March 28 [3 favorites]


More than anything, these stories are really reminding me more and more of military service, except in military service if you break the soldiers under you, there's consequences. Does anyone look at the staff doctors when residents are committing suicide?
posted by corb at 2:46 PM on March 28 [4 favorites]


Since there are so many doctors and people in close contact with doctors in this thread, I have to ask while I can. How can you manage to stay awake and functional for so long? Is it a learned skill? Some amount of resilience that you either do or do not have?

I would echo all the prior comments on this issue. Also have to acknowledge the incalculable number of potential fuckups and catastrophes averted by nurses and pharmacists who catch errors from staff doctors before they are put into action, always diplomatically and without drama or accusation. And age is a huge issue. How I was so stupid to think this I will never know, but starting practice in my late 20's I very wrongly assumed that the old docs in my practice did fine on call because they needed less sleep when the opposite seems true now that I'm 50+.

Medical training is a very poor facsimile of real medical practice. Hopefully people in training who find it emotionally draining can recognize the difference and hang on until they can get into real world practice, where there is often quite a rewarding life waiting.
posted by docpops at 3:12 PM on March 28 [1 favorite]


Fragmentation / non continuity of care remains a critical roadblock to reducing hours in not just the medical profession but in the economy as whole. For any job that requires continuity of knowledge (either a doctor caring for a patient or an engineer designing a solution to a problem), trying to replace one person working 5 days a week with say, two part timers, one doing Mon-Wed and the other doing Thu-Fri, is going to lead to a drastic drop in work performance.

Unfortunately (?) this argument just doesn't hold up, because all the available evidence suggests that people's performance at just about any kind of work drops off dramatically after some number of hours. So the problem of fragmentation is just not solved by having fewer people working more hours.

(Also, I have to say, for the doctors I know your person X M-W and person Y Th-Fri example actually sounds a lot closer to practice, except that these are minimum 12 hour shifts on each of those days and it's more or less randomly assigned (well, with seniority factored in) months in advance who gets which weekday permutations.)
posted by advil at 3:41 PM on March 28 [4 favorites]


I've known 2 people who died of suicide: My roommate from my first year of medical school, who went off to medical school herself across the country a year later, and who killed herself during her third year after failing a rotation. The other was my anatomy professor, who was a beloved figure of decades at the school. Professional pressures and a sense of inadequacy and failure seem to have been the driving force for both deaths.

As someone who works pretty closely with medical students and residents, I would suggest that medical schools have actually gotten pretty good about at least identifying issues around mental health and wellness, and that residency programs (while much more variable) are often at least aware of the issue. The large program where I am faculty devotes a lot of time and attention to resident feedback and tries to make a lot of accommodations.

I think slarty bartfast has it right, though, in that medical school and residency are tough, but most people expect them to be difficult and there's often a lot of camaraderie and mutual support from your colleagues in the same position. Coming out as an attending physician, you can be working the same or even more time depending on specialty, with the expectation that you'll spend all your "work" time seeing patients and attending to their needs and then spend additional hours every day documenting the work you did and taking care of increasingly cumbersome paperwork.
posted by The Elusive Architeuthis at 4:48 PM on March 28


In an interesting coincidence, I spent all day today in a retreat for med students and faculty devoted to the topic of lowering rates of depression, anxiety, and suicide among medical students. There was a keynote from the author of this JAMA editorial that discussed ways we can increase our own resilience, but that focused primarily on environmental factors that can be changed. As he put it: med students are pretty resilient to begin with, and trying to fix us one at a time (rather than fixing the environment that affects all of us) is a losing proposition.

It was a really useful and productive day, and one I'm glad we had so early during my clinical years (we're on a weird schedule; I just finished my very first rotation). There was one major thing missing, though, which was noted by both students and faculty: residents. As Mr. Yak notes, residents are a huge part of our education, and have their own overwhelming stresses. Any solutions to this problem have to include them.
posted by ocherdraco at 6:47 PM on March 28 [2 favorites]


I'm very sorry for your loss, hazyjane
posted by thelonius at 7:08 PM on March 28 [7 favorites]


So, I've actually been wanting to write about this for a while, but I am trying to wait until I'm in a position where I can talk about the issue with my IRL identity tied to it.

This problem is on everyone's mind in physician training, but awareness and attempts at destigmatizing mental health aren't going to change anything by themselves. There are myriad ways residency and school can bring about depression, and there is a lot of potential for any single program or system set up to combat depression is going to unintentionally make things worse for some people if it approaches the issue unilaterally. A lot can be written about these wholly preventable tragedies...

The one thing I want to say here: one of the worst things about training is how isolating it is. What makes that worse is not feeling like you can talk to your peers in training whom you're spending 80 hours a week with.
A lot of people never truly feel at ease around doctors, and sometimes training docs feel that way too. As much as I enjoy the work, I never fit in with other doctors myself, and chose a specialty where the dominant personality is pretty much the opposite of mine. One thing I want to tell every resident I meet is please please please find someone you can confide in, someone you feel safe with, someone who you can call on like an AA sponsor. If you don't know anyone at your facility like that, then memail me. Seriously. I'll give you my cell phone, my e-mail, my address, my pager, my facebook URL, iMessenger, all of them. Just try to find someone whom you can reach out to so you don't feel emotionally separated from the rest of world.
posted by midmarch snowman at 8:34 PM on March 28 [14 favorites]


How can you manage to stay awake and functional for so long? Is it a learned skill? Some amount of resilience that you either do or do not have?

It is a learned skill, yes.


Sure, like being a functional alcoholic. You learn to cover up the obvious signs of sleep deprivation even though a mountain of literature shows decision making and mental acuity go downhill and do not recover without sleep. Someone treating you at the end of an all nighter is functionally drunk. Nobody who cares about results should be doing this shit. Truck drivers are held to higher standards.
posted by benzenedream at 4:20 PM on April 1 [2 favorites]


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