300 to 400 physicians a year in the US take their own lives...
September 27, 2023 4:54 PM Subscribe
US surgeons are killing themselves at an alarming rate. One decided to speak out “I was the top junior tennis player in the United States,” she began. “I am an associate professor of surgery at Harvard.
“But I am also human. I am a person with lifelong depression, anxiety, and now a substance use disorder.”
The room fell silent.
“But I am also human. I am a person with lifelong depression, anxiety, and now a substance use disorder.”
The room fell silent.
It's got to be absolutely hell on most of these folks who are full blown Type A, hyper competitive types. It's bad enough when you're not that ambitious and competitive. (I went through a rude awakening that sent me spiraling when I went to college and I'm not that much ofa striver.)
COVID caused a lot of people's gears to slip and then grind into dust. Looking at a UK report pegs the risk of suicide for any doctor to be 2-5 times that of the average population. (I know for veterinarians it's the same problem, exacerbated by not getting the same level of respect as an MD)
The harsh self-drive, the need to see more and more patients, do more with less resources and time and a general sense that the nasty among us has been empowered to let their abusive flag fly. (And I hate to harbor a guess that more women in the professions allow some wonderful bouts of misogyny - I know the vet world is now majority female at ~63%)
posted by drewbage1847 at 5:42 PM on September 27, 2023 [12 favorites]
COVID caused a lot of people's gears to slip and then grind into dust. Looking at a UK report pegs the risk of suicide for any doctor to be 2-5 times that of the average population. (I know for veterinarians it's the same problem, exacerbated by not getting the same level of respect as an MD)
The harsh self-drive, the need to see more and more patients, do more with less resources and time and a general sense that the nasty among us has been empowered to let their abusive flag fly. (And I hate to harbor a guess that more women in the professions allow some wonderful bouts of misogyny - I know the vet world is now majority female at ~63%)
posted by drewbage1847 at 5:42 PM on September 27, 2023 [12 favorites]
Thank you for posting this
posted by basalganglia at 5:49 PM on September 27, 2023 [3 favorites]
posted by basalganglia at 5:49 PM on September 27, 2023 [3 favorites]
Halloween Jack's comment reminds me of a gruesome, amazing show from 2014-2015, The Knick. Amazing soundtrack (Cliff Martinez), but really well-done drama about advances in medicine in the turn of the century from 1800s to 1900s, starring Clive Owen, Eve Hewson, and directed by Steven Soderbergh.
posted by room9 at 7:15 PM on September 27, 2023 [11 favorites]
posted by room9 at 7:15 PM on September 27, 2023 [11 favorites]
A guy at church is a doctor, and his wife's a doctor, and their older child is in med school. I have talked to him about med school since one of my kids wants to be a PA or MD or something and, while I forgot his specific words, he does not approve of the current, destructive model of doctor training.
Why would you ruin people, most of whom who won't ever work that kind of schedule again?? It's hazing.
posted by wenestvedt at 8:00 PM on September 27, 2023 [25 favorites]
Why would you ruin people, most of whom who won't ever work that kind of schedule again?? It's hazing.
posted by wenestvedt at 8:00 PM on September 27, 2023 [25 favorites]
This afternoon I finished a book, When Breath Becomes Air. I'd recommend it to anyone. It explores in depth the training, hardships, intensity, etc. involved in becoming a surgeon. In this case, a neurosurgeon, who becomes a lung cancer victim, and who details the progress of his disease. He dies. There is more...
posted by kozad at 8:05 PM on September 27, 2023 [2 favorites]
posted by kozad at 8:05 PM on September 27, 2023 [2 favorites]
You're right Will.
Your anecdote reminded me of how academia has a similar culture.
Stories of grad students living in the lab are commonplace, and mental-health problems are the elephant in the room there as well.
posted by rbanerjee at 8:15 PM on September 27, 2023 [9 favorites]
Your anecdote reminded me of how academia has a similar culture.
Stories of grad students living in the lab are commonplace, and mental-health problems are the elephant in the room there as well.
posted by rbanerjee at 8:15 PM on September 27, 2023 [9 favorites]
His oddities, though, were tolerated because of the enormity of his achievements.
I imagine that very few instances of the use of 'enormity' have achieved the balance between the poles of its meaning that this one has.
posted by jamjam at 8:24 PM on September 27, 2023 [8 favorites]
I imagine that very few instances of the use of 'enormity' have achieved the balance between the poles of its meaning that this one has.
posted by jamjam at 8:24 PM on September 27, 2023 [8 favorites]
All of those years of hazing, all of those years of dissociation as a maladaptive strategy for professional survival…so that patients could scream racist accusations about Covid, and demand ivermectin prescriptions OR ELSE, often followed by news of their hospitalization and/or death. I saw it happen. The silent moral injury is real and dangerous, and the healers are not okay./
posted by MonkeyToes at 8:56 PM on September 27, 2023 [28 favorites]
posted by MonkeyToes at 8:56 PM on September 27, 2023 [28 favorites]
It's bonkers how self-perpetuating these unnecessary and harmful professional practices are. The hazing and dues-earning culture is so strong, nobody wants to let the next generation of doctors have it any easier. Imagine if the profession banded together as a labor union: how powerful they could be in setting their own terms.
posted by amusebuche at 9:45 PM on September 27, 2023 [8 favorites]
posted by amusebuche at 9:45 PM on September 27, 2023 [8 favorites]
Is surgeon culture in the rest of the world different, or somehow also descended from William Halsted, or what?
posted by clew at 9:48 PM on September 27, 2023 [3 favorites]
posted by clew at 9:48 PM on September 27, 2023 [3 favorites]
Halsted and his colleague Osler brought a form of the system over from Germany and Austria to Johns Hopkins; Osler later transplanted it to the UK.
posted by praemunire at 10:59 PM on September 27, 2023 [5 favorites]
posted by praemunire at 10:59 PM on September 27, 2023 [5 favorites]
Why would you ruin people, most of whom who won't ever work that kind of schedule again??
I am not a doctor myself, but I have family members and friends who are (comes with mixing in the same families and circles I guess).
The impression I get is that those hours are necessary because you're never going to pass the exams on 40 hours a week - you don't accumulate the experience and knowledge and expertise at a fast enough rate at 40 hours a week to become a safe doctor within a reasonable period of time, which means extending the time you need to remain under supervision (and it already takes up to 10 years to be fully qualified).
One person I knew went to a rural town (those people need healthcare after all) and because they were only doing effectively 20-30 hours a week of work they failed their exams and were at risk of being permanently kicked out of the college (they only allow you 1-2 failures and then they judge that you're not worth taking up a critical spot in the system that could be used to train a more promising doctor). They then moved to a different town and did 70 hours a week and then passed the exams next go, and reflected that this was a more appropriate workload for sharpening their skills. You need to see a huge number of patients so the 1% or 0.5% outliers don't trip you up, and you become confident in diagnosing and treating them (like they say, an engineer could build 100 safe bridges, but he is only known for the 1 that collapsed and killed a dozen people). The doctors who know what's up actively seek out that level of workload, if you're not getting that level of work, your future is a dead end.
posted by xdvesper at 12:22 AM on September 28, 2023 [10 favorites]
I am not a doctor myself, but I have family members and friends who are (comes with mixing in the same families and circles I guess).
The impression I get is that those hours are necessary because you're never going to pass the exams on 40 hours a week - you don't accumulate the experience and knowledge and expertise at a fast enough rate at 40 hours a week to become a safe doctor within a reasonable period of time, which means extending the time you need to remain under supervision (and it already takes up to 10 years to be fully qualified).
One person I knew went to a rural town (those people need healthcare after all) and because they were only doing effectively 20-30 hours a week of work they failed their exams and were at risk of being permanently kicked out of the college (they only allow you 1-2 failures and then they judge that you're not worth taking up a critical spot in the system that could be used to train a more promising doctor). They then moved to a different town and did 70 hours a week and then passed the exams next go, and reflected that this was a more appropriate workload for sharpening their skills. You need to see a huge number of patients so the 1% or 0.5% outliers don't trip you up, and you become confident in diagnosing and treating them (like they say, an engineer could build 100 safe bridges, but he is only known for the 1 that collapsed and killed a dozen people). The doctors who know what's up actively seek out that level of workload, if you're not getting that level of work, your future is a dead end.
posted by xdvesper at 12:22 AM on September 28, 2023 [10 favorites]
This is some anecdotal information about someone in my family. I know it doesn't apply universally.
I am related to a person who has been an ER doctor for a long time. I want to state right now that I care about this person and respect a whole lot of what they do. I'm told they used to be kind, jovial, and empathetic.
And then, they went to med school.
The work schedule alone in hospitals would wreck almost anyone. Weird rotating 12-hour shifts with seemingly no rhyme or reason. Common sense would tell you that the people who studied the human body in detail might use that knowledge to come up with a sensible alternative. However, I've observed the same awful scheduling from three very different hospitals. One hospital in particular decided that it was bad form to have staff catching naps during times when nothing was happening, especially on night shift, so they removed the cots or recliners from what had been a designated space for people to rest and turned it into something else entirely. I can only imagine that this results in something like permanent jet lag.
I also don't think I've ever seen my relative enjoy food. Food is fuel for them. Consumed quickly, never savored. Family members have commented that this was a very dramatic change from previous behaviors.
ER docs see horrific shit. And stupid shit. I've never heard about any recommendations for my relative to get any kind of counseling. I tried to ask about it once. I guess it's considered by some to be both weak and a waste of time.
I've spent quite a bit of time over many years with this person, and I don't think I've ever seen them express anything resembling real joy. I'm told that they used to. It doesn't help that they now have the stereotypical ego and that their opinion of others who don't share their seemingly endless drive is always terrible. The word "lazy" gets used a lot. There is obvious contempt for people who tend to be more easygoing no matter how successful they are.
I can see the need to make sure that folks who have to be able to act under pressure should be trained for it. That should apply to a lot of folks: first responders, military, etc. I understand the point of boot camp. But it seems to me that medical training is overkill and often cruel.
It was never a surprise to me that so many folks just couldn't work in hospitals any more after surge upon surge of covid. Between the harsh training conditions and the administrators constantly chasing profit, I was always surprised that hospitals were adequately staffed in the first place.
Now, I know that this is just one person and only my limited observations along with some family gossip. It very well could be that my relative is simply an asshole and always has been. However, their situation has made me question who thinks this kind of system remains helpful to both the doctors and their patients. Because what I see is a person who automatically thinks their patients (and family members and non-doctor coworkers) are lazy fools and/or liars and who seems to get no good or healthy satisfaction out of their job or their private life. The most sad thing to me is that they appear to not have any friends.
I'm happy for someone to explain it to me because I just cannot see any logical reason for the mistreatment that starts in med school to continue for potentially the rest of someone's life. No wonder they get so tired and are just done.
posted by lilywing13 at 1:05 AM on September 28, 2023 [21 favorites]
I am related to a person who has been an ER doctor for a long time. I want to state right now that I care about this person and respect a whole lot of what they do. I'm told they used to be kind, jovial, and empathetic.
And then, they went to med school.
The work schedule alone in hospitals would wreck almost anyone. Weird rotating 12-hour shifts with seemingly no rhyme or reason. Common sense would tell you that the people who studied the human body in detail might use that knowledge to come up with a sensible alternative. However, I've observed the same awful scheduling from three very different hospitals. One hospital in particular decided that it was bad form to have staff catching naps during times when nothing was happening, especially on night shift, so they removed the cots or recliners from what had been a designated space for people to rest and turned it into something else entirely. I can only imagine that this results in something like permanent jet lag.
I also don't think I've ever seen my relative enjoy food. Food is fuel for them. Consumed quickly, never savored. Family members have commented that this was a very dramatic change from previous behaviors.
ER docs see horrific shit. And stupid shit. I've never heard about any recommendations for my relative to get any kind of counseling. I tried to ask about it once. I guess it's considered by some to be both weak and a waste of time.
I've spent quite a bit of time over many years with this person, and I don't think I've ever seen them express anything resembling real joy. I'm told that they used to. It doesn't help that they now have the stereotypical ego and that their opinion of others who don't share their seemingly endless drive is always terrible. The word "lazy" gets used a lot. There is obvious contempt for people who tend to be more easygoing no matter how successful they are.
I can see the need to make sure that folks who have to be able to act under pressure should be trained for it. That should apply to a lot of folks: first responders, military, etc. I understand the point of boot camp. But it seems to me that medical training is overkill and often cruel.
It was never a surprise to me that so many folks just couldn't work in hospitals any more after surge upon surge of covid. Between the harsh training conditions and the administrators constantly chasing profit, I was always surprised that hospitals were adequately staffed in the first place.
Now, I know that this is just one person and only my limited observations along with some family gossip. It very well could be that my relative is simply an asshole and always has been. However, their situation has made me question who thinks this kind of system remains helpful to both the doctors and their patients. Because what I see is a person who automatically thinks their patients (and family members and non-doctor coworkers) are lazy fools and/or liars and who seems to get no good or healthy satisfaction out of their job or their private life. The most sad thing to me is that they appear to not have any friends.
I'm happy for someone to explain it to me because I just cannot see any logical reason for the mistreatment that starts in med school to continue for potentially the rest of someone's life. No wonder they get so tired and are just done.
posted by lilywing13 at 1:05 AM on September 28, 2023 [21 favorites]
In the UK junior doctors are protected by the Working Time Regulations which incorporate the European Working Time Directive. Average working week must be no more than 48 hours, and there are clear rules about minimum rest times. You cannot opt out of the rest breaks.
I don't know how exactly it works in practice, but the BMA is a fairly strong professional body.
posted by plonkee at 4:57 AM on September 28, 2023 [3 favorites]
I don't know how exactly it works in practice, but the BMA is a fairly strong professional body.
posted by plonkee at 4:57 AM on September 28, 2023 [3 favorites]
xdvesper, thanks for your post. I'm a doctor, about to finish a decade of training (finally!!!), and I entirely agree with you. And to be fair, it's not just about passing artificial exams, but about real-world competence.
Cutting trainee hours isn't the silver bullet I wish it was. There's just a hell of a lot to learn, and trading weekly hours at the hospital for extra years of training isn't an easy call, at least not the way I see things. Ten and a half years has been just plenty for me, thanks. Of course I didn't enjoy spending so many nights on call over the last years -- but I'm not sure my overall wellness would have been any better if I'd had to train for longer, with more years of absorbing the miseries of being at the bottom of the hospital hierarchy, and of uncertainty about whether I'll even land a job after devoting so much of my life to my training (yes, this is a concern in my field).
I don't think there's a straightforward change to training schedules that would fix this, because yes, I do worry that trainees won't be prepared to safely practice independently if they work normal human hours for a reasonable number of years. It's a problem. It sucks.
For now, I do think that my colleagues and I can push back against the glorification of work addiction -- to start seeing our workload as the burden it is, rather than as a source of identity and pride, and to start talking to trainees about it in those terms instead of the relentless positivism and empty wellness-speak that I endured. Maybe that would help to prevent some of us from proceeding down the path of your relative, lilywing13, and other docs who see normalcy as weakness.
posted by saturday_morning at 6:12 AM on September 28, 2023 [14 favorites]
Cutting trainee hours isn't the silver bullet I wish it was. There's just a hell of a lot to learn, and trading weekly hours at the hospital for extra years of training isn't an easy call, at least not the way I see things. Ten and a half years has been just plenty for me, thanks. Of course I didn't enjoy spending so many nights on call over the last years -- but I'm not sure my overall wellness would have been any better if I'd had to train for longer, with more years of absorbing the miseries of being at the bottom of the hospital hierarchy, and of uncertainty about whether I'll even land a job after devoting so much of my life to my training (yes, this is a concern in my field).
I don't think there's a straightforward change to training schedules that would fix this, because yes, I do worry that trainees won't be prepared to safely practice independently if they work normal human hours for a reasonable number of years. It's a problem. It sucks.
For now, I do think that my colleagues and I can push back against the glorification of work addiction -- to start seeing our workload as the burden it is, rather than as a source of identity and pride, and to start talking to trainees about it in those terms instead of the relentless positivism and empty wellness-speak that I endured. Maybe that would help to prevent some of us from proceeding down the path of your relative, lilywing13, and other docs who see normalcy as weakness.
posted by saturday_morning at 6:12 AM on September 28, 2023 [14 favorites]
saturday_morning - yes that echoes the sentiments of my family members - obviously they were disappointed they failed the exams, but it was abundantly clear that the exams reflected real life competence so they simply weren't ready to operate independently. They studied for the exams alongside an experienced colleague from another country with 20 years experience who had to be re-certified to practice here, and that colleague aced the exams, so the exams really do measure what they're meant to do. It takes thousands of hours to be a safe doctor, and if you halve the work hours you double the time it takes to get qualified. Obviously it's a sign of system failure if doctors are driven to suicide due to the pressure: perhaps there needs to be a relief valve where, ok, you're not cut out to be on what we understand to be the traditional track, so here are some offramps and pathways where you still get to use your training in a less stressful environment.
I have the opposite anecdote of one particular ER / ED doctor -he is one of the most relaxed, jovial, patient and kind person I know, with 3 kids. Fully qualified, he would earn $500k per year in the public system. I asked him why he is so passionate about ED work when it's renowned to be one of the worst for burnout, and he said he has the memory of a goldfish, he takes in patients and he has no idea what their prior history is, he just stabilizes them so they aren't actively dying and then shoves them off to a different part of the hospital for another doctor to fix. Then he finishes his shift and goes home and never has to think about those patients ever again.
(Compared to doctors who are involved in the end-to-end care of the patient - understanding their history, diagnosing their disease, calming their fears, coming up with a treatment plan and convincing them it's the right course of action, then following it through to either a cure or death - which can take months)
posted by xdvesper at 6:32 AM on September 28, 2023 [8 favorites]
I have the opposite anecdote of one particular ER / ED doctor -he is one of the most relaxed, jovial, patient and kind person I know, with 3 kids. Fully qualified, he would earn $500k per year in the public system. I asked him why he is so passionate about ED work when it's renowned to be one of the worst for burnout, and he said he has the memory of a goldfish, he takes in patients and he has no idea what their prior history is, he just stabilizes them so they aren't actively dying and then shoves them off to a different part of the hospital for another doctor to fix. Then he finishes his shift and goes home and never has to think about those patients ever again.
(Compared to doctors who are involved in the end-to-end care of the patient - understanding their history, diagnosing their disease, calming their fears, coming up with a treatment plan and convincing them it's the right course of action, then following it through to either a cure or death - which can take months)
posted by xdvesper at 6:32 AM on September 28, 2023 [8 favorites]
Halsted didn't invent the slavish remoteness of practicing medicine. So much of the field has roots in religious Christian establishments of various stripes. Work is faith, faith is life, piety must be demonstrated in the magnitude of fealty I give to caring for others. The Nightingale Pledge comes to mind.
When I was in gad school early in the millennium, I was struggling to pay bills along with tuition. I made ends meet by working nights in a sex club and, as one does, using the opportunity to sell illicit substances to the people who would come there desperate for some kind of release from their daytime lives. Let me tell you, there were a lot of doctors, especially surgeons, in the ranks. Some of the most out-of-their-minds I've ever seen people get in my entire life were the exhausted-looking medical faculty I'd see in scrubs and suits during the day but strung out and yielding to high risk activities the one weekend they'd spin out every 4-6 weeks. It genuinely diverted me out of the MD pathway and into non-clinical practice.
posted by late afternoon dreaming hotel at 6:38 AM on September 28, 2023 [17 favorites]
When I was in gad school early in the millennium, I was struggling to pay bills along with tuition. I made ends meet by working nights in a sex club and, as one does, using the opportunity to sell illicit substances to the people who would come there desperate for some kind of release from their daytime lives. Let me tell you, there were a lot of doctors, especially surgeons, in the ranks. Some of the most out-of-their-minds I've ever seen people get in my entire life were the exhausted-looking medical faculty I'd see in scrubs and suits during the day but strung out and yielding to high risk activities the one weekend they'd spin out every 4-6 weeks. It genuinely diverted me out of the MD pathway and into non-clinical practice.
posted by late afternoon dreaming hotel at 6:38 AM on September 28, 2023 [17 favorites]
Does this article in any place show that surgeons commit suicide at any higher rate than the general population, or the population of people with the intelligence, ambition and tenacity which are required of surgeons? Or have higher rates of substance abuse vs. either cohort? It does say ~12% of doctor suicides are surgeons which is ... statistically in line with the percentage of doctors who are surgeons?
posted by MattD at 6:46 AM on September 28, 2023 [3 favorites]
posted by MattD at 6:46 AM on September 28, 2023 [3 favorites]
ER docs see horrific shit. And stupid shit. I've never heard about any recommendations for my relative to get any kind of counseling. I tried to ask about it once. I guess it's considered by some to be both weak and a waste of time.
In some states your license, that you worked so hard for and gave up so much for, can be at risk if you have a "mental disorder", and many doctors pay cash and use false names to see psychiatrists and therapists.
Also, if you're ever been subject to the tender ministrations of ER doctors and nurses with the label "psych patient" attached, you can probably understand why they themselves might be keen to avoid it.
posted by threementholsandafuneral at 7:14 AM on September 28, 2023 [17 favorites]
In some states your license, that you worked so hard for and gave up so much for, can be at risk if you have a "mental disorder", and many doctors pay cash and use false names to see psychiatrists and therapists.
Also, if you're ever been subject to the tender ministrations of ER doctors and nurses with the label "psych patient" attached, you can probably understand why they themselves might be keen to avoid it.
posted by threementholsandafuneral at 7:14 AM on September 28, 2023 [17 favorites]
This knowledge makes me feel guilty for seeking medical care. I don't want to add to the burdens of people who are already suffering.
posted by Faint of Butt at 8:36 AM on September 28, 2023 [3 favorites]
posted by Faint of Butt at 8:36 AM on September 28, 2023 [3 favorites]
The funny part about the fear of getting your license pulled is all the stories I know (admittedly few) make it seems like a herculean task to get a license pulled. There was one psych here in my town who had multiple physical altercations with his staff and patients, got cited for drug use, had his license suspended and then finally, finally got it revoked after years of abusive behavior that made it to the courts.
Meanwhile, this doc in the article gets put through the ringer the second she says " I have a problem"
posted by drewbage1847 at 8:54 AM on September 28, 2023 [6 favorites]
Meanwhile, this doc in the article gets put through the ringer the second she says " I have a problem"
posted by drewbage1847 at 8:54 AM on September 28, 2023 [6 favorites]
Sometimes I can't help but think that this type of training specifically selects for doctors who won't organize when being taken advantage of.
posted by MrVisible at 9:00 AM on September 28, 2023 [5 favorites]
posted by MrVisible at 9:00 AM on September 28, 2023 [5 favorites]
"if you halve the work hours you double the time it takes to get qualified."
This is the part I don't get. My understanding of how brains work is that you're not going to learn twice as much from a 12-hour day as you are from a six-hour day. You just don't learn as well when you're tired. You need down time to absorb new ideas.
I mean, I'm no expert, this is just based on random popular journalism and my own limited experience as an owner of a brain. And maybe there's something specific about the kind of learning doctors do--from xdvesper's description, maybe a lot of those long hours is spent doing routine work while waiting for the occasional outlier to come along, and maybe there are fewer substitutes for hands-on experience with those outliers. (Surely e.g. pilot skill level is also determined by ability to handle extremely rare situations, but maybe there's no equivalent to flight simulators for doctors?)
Still I'm skeptical that on average the n+1st hour is a day is as valuable as the nth...
posted by bfields at 9:01 AM on September 28, 2023 [16 favorites]
This is the part I don't get. My understanding of how brains work is that you're not going to learn twice as much from a 12-hour day as you are from a six-hour day. You just don't learn as well when you're tired. You need down time to absorb new ideas.
I mean, I'm no expert, this is just based on random popular journalism and my own limited experience as an owner of a brain. And maybe there's something specific about the kind of learning doctors do--from xdvesper's description, maybe a lot of those long hours is spent doing routine work while waiting for the occasional outlier to come along, and maybe there are fewer substitutes for hands-on experience with those outliers. (Surely e.g. pilot skill level is also determined by ability to handle extremely rare situations, but maybe there's no equivalent to flight simulators for doctors?)
Still I'm skeptical that on average the n+1st hour is a day is as valuable as the nth...
posted by bfields at 9:01 AM on September 28, 2023 [16 favorites]
Anecdotal I know - I was for a few years considering a "late in life" (by medicine standards) shift to medicine for a career. Having a fair number of US based physician friends, and having lived with them/seen them go through the brutal madness of residency lead me to read up the process to help understand what I might be signing up for.
Additionally, as a person with dual citizenship in the EU, and trying to be mindful of finances, I looked at the schooling and residency process in Europe, including spending time on bulletin boards and subreddits devoted to residency. The argument that "you must put in the time" or "cutting resident hours is not a silver bullet," does not seem supported by the facts. Virtually the entire EU works 40-60 hours a week in their residency programs, with European style vacations. They don't spend appreciably longer in their specializations, and medical outcomes are often times much better than in the US.
The real reason the residency system continues to thrive in the US is less some desire to put young trainees through the same hazing attendings experienced, or just because we're so darn thorough and rigorous here (you lazy Euros!), and more because of how the funding works. Residents are cheap labor. The US government funds resident positions to training hospitals, the hospitals pay residents a small fraction of this funding and pocket the rest for "training costs," all while having them work absurd hours, and effectively encouraging them to lie about it - as there are new requirements in place to ensure residents don't work over 80 hours a week (lol).
Past the intern year, and especially deeper into residency for less technical/shorter residencies, residents effectively are cheaper than nurses in many places acting as MDs, and shoulder a massive amount of care.
Residency is a brutal system that does not produce better medical outcomes, and it is perpetuated for financial reasons by our for-profit medical system.
Edit: Note that it is extremely difficult to come into the US system from Non-US medical schools for residency, and even fully credentialed, experienced physicians who've worked for years in other countries, including the EU are required to re-board and sometimes do a year or more of "residency" all over again to enter. The supply of residency positions is artificially constrained by congressional action that was driven by the AMAs desire to keep the supply low in the 1980/90s and protect income. The whole system is a giant mess of historical incentives gone awry.
posted by DarlingMonster at 9:56 AM on September 28, 2023 [35 favorites]
Additionally, as a person with dual citizenship in the EU, and trying to be mindful of finances, I looked at the schooling and residency process in Europe, including spending time on bulletin boards and subreddits devoted to residency. The argument that "you must put in the time" or "cutting resident hours is not a silver bullet," does not seem supported by the facts. Virtually the entire EU works 40-60 hours a week in their residency programs, with European style vacations. They don't spend appreciably longer in their specializations, and medical outcomes are often times much better than in the US.
The real reason the residency system continues to thrive in the US is less some desire to put young trainees through the same hazing attendings experienced, or just because we're so darn thorough and rigorous here (you lazy Euros!), and more because of how the funding works. Residents are cheap labor. The US government funds resident positions to training hospitals, the hospitals pay residents a small fraction of this funding and pocket the rest for "training costs," all while having them work absurd hours, and effectively encouraging them to lie about it - as there are new requirements in place to ensure residents don't work over 80 hours a week (lol).
Past the intern year, and especially deeper into residency for less technical/shorter residencies, residents effectively are cheaper than nurses in many places acting as MDs, and shoulder a massive amount of care.
Residency is a brutal system that does not produce better medical outcomes, and it is perpetuated for financial reasons by our for-profit medical system.
Edit: Note that it is extremely difficult to come into the US system from Non-US medical schools for residency, and even fully credentialed, experienced physicians who've worked for years in other countries, including the EU are required to re-board and sometimes do a year or more of "residency" all over again to enter. The supply of residency positions is artificially constrained by congressional action that was driven by the AMAs desire to keep the supply low in the 1980/90s and protect income. The whole system is a giant mess of historical incentives gone awry.
posted by DarlingMonster at 9:56 AM on September 28, 2023 [35 favorites]
And one last note - Residents are paid a pittance. Effectively making less than the federal minimum hourly wage, often in very HCOL areas. This all goes on while they're accruing interest on tens or hundreds of thousands of dollars of loan payments. The entire system is just labor exploitation at its most perfectly post-industrial cruelty. Many residency programs have begun unionizing, to great effect, but physicians as a profession feel (and are indoctrinated) to view the job as "a calling" raising all sorts of weird moral issues about striking. This last year saw one of the largest waves of residency program unionizations ever.
posted by DarlingMonster at 10:03 AM on September 28, 2023 [12 favorites]
posted by DarlingMonster at 10:03 AM on September 28, 2023 [12 favorites]
I worked at a dental school. One year they featured some speakers for the faculty on what they claimed, that dentists as a profession had the highest rate of suicide and drug abuse of any profession. Getting certified as a dentist, in California, requires having an AA or BA/BS degree, completing a training at a certified dental school, about 3 to 4 years, and passing a state board exam. There was competition between students but nothing like medical school. After getting your DDS degree, it just required getting hired into an existing dental practice or starting your own. None of this insane intern/resident stuff. So why are dentists suffering from the same bad outcomes of surgeons?
posted by njohnson23 at 10:08 AM on September 28, 2023 [2 favorites]
posted by njohnson23 at 10:08 AM on September 28, 2023 [2 favorites]
US medical residents make around $60,000/yr. The federal minimum wage is $7.25. That comes out to ~160 hours per week. They work too much, but not that much.
posted by obfuscation at 10:10 AM on September 28, 2023 [1 favorite]
posted by obfuscation at 10:10 AM on September 28, 2023 [1 favorite]
So why are dentists suffering from the same bad outcomes of surgeons?
They're always down in the mouth.
posted by riruro at 10:11 AM on September 28, 2023 [6 favorites]
They're always down in the mouth.
posted by riruro at 10:11 AM on September 28, 2023 [6 favorites]
$60,000/yr in some areas, at some hospitals, once you've been at it a while. Residency salaries are highly variable, and the added requirements of being on call tack on "time off" that isn't really down time. So yes, a bit of hyperbole on my part, in terms of the universality of it, so, apologies there.
I've lived with pediatric residents, one of the less demanding specialties, who would work 15 days straight, 12-15 hours a days at the hospital, and then come home and do paper work for hours before passing out. The published statistics on hours from hospital groups and regulations are very skewed in their representations of what counts as "working hours" - often residents have their posted shifts - and then the reality of having to stay on because of rushes. Not to mention when they're "off" having to catch up on charting and paperwork that is not tracked as working hours.
posted by DarlingMonster at 10:14 AM on September 28, 2023 [2 favorites]
I've lived with pediatric residents, one of the less demanding specialties, who would work 15 days straight, 12-15 hours a days at the hospital, and then come home and do paper work for hours before passing out. The published statistics on hours from hospital groups and regulations are very skewed in their representations of what counts as "working hours" - often residents have their posted shifts - and then the reality of having to stay on because of rushes. Not to mention when they're "off" having to catch up on charting and paperwork that is not tracked as working hours.
posted by DarlingMonster at 10:14 AM on September 28, 2023 [2 favorites]
Thanks for sharing this article.
I am curious to hear more from the physicians in this thread, with the understanding that we all have trouble imagining a different world before we live in it.
How could this crisis be different if:
- Congress doubled funding for residency slots
- The AMA stopped lobbying against NPs, PAs, Nurse-Midwives, Nurse-Anesthetists etc practicing independently
- Immigration policy was more supportive of immigrant providers
- Medical school was a 6 year program continuous with the bachelors, instead of an additional 4 year program on top of the bachelors
- Medical school at public universities and HBCUs was subsidized/free at point of service
- A culture of collaboration and curiosity allowed physicians more opportunities for mentorship and supported learning after completion of residences
- FQHCs & public hospitals were robustly funded and Medicaid reimbursement rates matched private insurance reimbursement rates , and pay and benefits at these clinics were adequate to maintain full staffing
To my mind, some combination of the above policy changes could create conditions where reduction in residency training time - per day and overall - could be safely implemented. What do others think?
posted by latkes at 10:40 AM on September 28, 2023 [5 favorites]
I am curious to hear more from the physicians in this thread, with the understanding that we all have trouble imagining a different world before we live in it.
How could this crisis be different if:
- Congress doubled funding for residency slots
- The AMA stopped lobbying against NPs, PAs, Nurse-Midwives, Nurse-Anesthetists etc practicing independently
- Immigration policy was more supportive of immigrant providers
- Medical school was a 6 year program continuous with the bachelors, instead of an additional 4 year program on top of the bachelors
- Medical school at public universities and HBCUs was subsidized/free at point of service
- A culture of collaboration and curiosity allowed physicians more opportunities for mentorship and supported learning after completion of residences
- FQHCs & public hospitals were robustly funded and Medicaid reimbursement rates matched private insurance reimbursement rates , and pay and benefits at these clinics were adequate to maintain full staffing
To my mind, some combination of the above policy changes could create conditions where reduction in residency training time - per day and overall - could be safely implemented. What do others think?
posted by latkes at 10:40 AM on September 28, 2023 [5 favorites]
@latkes - based on all the time I spent looking into it - these proposals would have a huge effect in tackling the problem, with a couple exceptions.
Residency funding would need to be more than just more cash - it would require standing up real, good residency programs at hospitals around the country. One issue with residency is that some programs are way, way, way worse than others - having both very toxic cultures while also being far nastier with hours/call/etc., Some folks have reasonable residency experiences with a lot of work, but not life crushing, many do not, and properly monitoring and auditing these programs, while ensuring residents don't fear retaliation (their entire lives are held in the hands of their medical directors) would be needed too.
The lobbying against NP and other practitioners is driven in a part by desire to protect income/labor - but also many of those credentials have huge issues themselves. Being an NP used to be reserved for RNs who had spent many years working bedside, now it has for many (not all! I have a great NP I go to!) become a degree mill system. Bang out a BSN, do a year on the floor, and then jump into an online masters program and voila - you're capable of practicing (in some 26ish states) without physician supervision. I've got a whole bunch of nearing-retirement age nurses in my family and their experience with newly minted NPs in the last few years has been universally terrible (they also generally think Physicians are kind of assholes most of the time). There will be a big wave of liability issues coming soon with NPs who do not have sufficient training causing big medical problems in the coming years. And again, one of the drivers behind NP free practice is...money...NPs make very good money, but usually less than half of an IM/Peds/FP attending, often with substantially less rigorous post graduate schooling, and training.
If it's not super obvious....i spent a lot of time considering the shift to medicine in many many forms, and ultimately ended up deciding to just stick with my "old" career. It's a real mess out there at every level.
posted by DarlingMonster at 10:50 AM on September 28, 2023 [7 favorites]
Residency funding would need to be more than just more cash - it would require standing up real, good residency programs at hospitals around the country. One issue with residency is that some programs are way, way, way worse than others - having both very toxic cultures while also being far nastier with hours/call/etc., Some folks have reasonable residency experiences with a lot of work, but not life crushing, many do not, and properly monitoring and auditing these programs, while ensuring residents don't fear retaliation (their entire lives are held in the hands of their medical directors) would be needed too.
The lobbying against NP and other practitioners is driven in a part by desire to protect income/labor - but also many of those credentials have huge issues themselves. Being an NP used to be reserved for RNs who had spent many years working bedside, now it has for many (not all! I have a great NP I go to!) become a degree mill system. Bang out a BSN, do a year on the floor, and then jump into an online masters program and voila - you're capable of practicing (in some 26ish states) without physician supervision. I've got a whole bunch of nearing-retirement age nurses in my family and their experience with newly minted NPs in the last few years has been universally terrible (they also generally think Physicians are kind of assholes most of the time). There will be a big wave of liability issues coming soon with NPs who do not have sufficient training causing big medical problems in the coming years. And again, one of the drivers behind NP free practice is...money...NPs make very good money, but usually less than half of an IM/Peds/FP attending, often with substantially less rigorous post graduate schooling, and training.
If it's not super obvious....i spent a lot of time considering the shift to medicine in many many forms, and ultimately ended up deciding to just stick with my "old" career. It's a real mess out there at every level.
posted by DarlingMonster at 10:50 AM on September 28, 2023 [7 favorites]
“I wish I could get those of you in this room that are struggling the courage it takes to seek help. But I can’t. I can promise you that people will show up for you as you would for anyone else who asked for help,”
Do no harm: listen and support people who tell you they're suffering rather than ostracize then for weakness. It's not up to the victims of the system to be brave, it's up to the people supporting the system to also support those the system harms.
posted by k3ninho at 3:39 PM on September 28, 2023
Do no harm: listen and support people who tell you they're suffering rather than ostracize then for weakness. It's not up to the victims of the system to be brave, it's up to the people supporting the system to also support those the system harms.
posted by k3ninho at 3:39 PM on September 28, 2023
So why are dentists suffering from the same bad outcomes of surgeons?
I've heard anecdotally that some of this is down to chronic pain from years of poor ergonomics on the job. Dentists are also more likely to have a private practice where they have all the stress of managing a small business.
posted by Blue Jello Elf at 3:41 PM on September 28, 2023
I've heard anecdotally that some of this is down to chronic pain from years of poor ergonomics on the job. Dentists are also more likely to have a private practice where they have all the stress of managing a small business.
posted by Blue Jello Elf at 3:41 PM on September 28, 2023
I can offer anecdotes from knowing quite a few physicians, and being married to one for 30 years. But a quick search of not quite up to date info compares suicide rates. I would have expected physicians to have fared much worse. Frankly, the data here offers some head scratchers. It's always tempting to read an article like the one in the OP and try to interpret reasons and solutions. But the data shows some surprising non healthcare industries have eye popping suicide rates. Perhaps it hints that suicide may not be directly linked to occupation as much as one might think.
posted by 2N2222 at 4:07 PM on September 28, 2023 [3 favorites]
posted by 2N2222 at 4:07 PM on September 28, 2023 [3 favorites]
One reason to take studies of suicide with a grain of salt is that determinations of whether a death is suicide or not are made by county medical examiners. These differ in the criteria they use. Many deaths are ambiguous - was it an accidental overdose or? was the asphixiation a way to increase sexual pleasure or?
In one instance I know of, the ME would only rule a death was suicide if there was a suicide note. In another instance, an ME would only rule suicide if there was a history of psychiaric diagnoses in the medical record.
If you're looking for trends, or to compare different groups you need to consider these sources of variability and maybe just look at cases within areas where the determination of cause of death is made by the same people over time. This of course is also problematic as suicide is fairly rare, so a particular area might have such small numbers as would make it problematic to draw conclusions.
You also don't know how many suicides were prevented - these may not even be reported anywhere
posted by jasper411 at 7:06 PM on September 28, 2023 [1 favorite]
In one instance I know of, the ME would only rule a death was suicide if there was a suicide note. In another instance, an ME would only rule suicide if there was a history of psychiaric diagnoses in the medical record.
If you're looking for trends, or to compare different groups you need to consider these sources of variability and maybe just look at cases within areas where the determination of cause of death is made by the same people over time. This of course is also problematic as suicide is fairly rare, so a particular area might have such small numbers as would make it problematic to draw conclusions.
You also don't know how many suicides were prevented - these may not even be reported anywhere
posted by jasper411 at 7:06 PM on September 28, 2023 [1 favorite]
"if you halve the work hours you double the time it takes to get qualified."
The UK moved from a system where the most junior doctor worked 80+ hour weeks with horrendous on-call, to a system where they work 50+ hours a week with protected rest periods. One additional year was added to post-grad training right at the start, and a lot more medical school and training posts were created.
Outcomes are fine, and people who have undergone the reduced hours training make up about a third of consultants already.
posted by plonkee at 1:30 AM on September 29, 2023 [5 favorites]
The UK moved from a system where the most junior doctor worked 80+ hour weeks with horrendous on-call, to a system where they work 50+ hours a week with protected rest periods. One additional year was added to post-grad training right at the start, and a lot more medical school and training posts were created.
Outcomes are fine, and people who have undergone the reduced hours training make up about a third of consultants already.
posted by plonkee at 1:30 AM on September 29, 2023 [5 favorites]
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