Saturday, October 3, 2009

Well Blog

There's some good discussion/cathartic rambling going on at the NYT Well Blog. If you are a frequent reader of the Well Blog, you may be familiar with the links to Dr. Pauline Chen's columns and the responses. In a nutshell, she is an academic surgeon and will often write something about a current issue in medicine, particularly regarding medical education/training. She usually starts with an anecdote from her own training/teaching experiences, then finds a recent study that addresses the main point of said anecdote, and ends by interviewing the author of the study who offers his/her ideas about how we might change the system. Often, she addresses topics that are "taboo" to discuss in the hospital, like this week's topic: when physicians, especially stressed out residents, have "distress" in their lives, it impacts the care they provide to patients.

Now my first response, as it often is to these columns, is, "did we really need to conduct a study to reach this conclusion that seems so obvious?" But since the culture of medicine is not to address issues related to stress/being overworked/ balance in life/etc, I guess unfortunately the answer is yes. What I enjoy most about the Well Blog referencing her columns are the comments that soon appear. Several players dominate the discussion:
1. MDs - usually we hear from current residents/young physicians about the hell of residency currently, older generation MDs whining about how easy our generation has it or about how much medicine now sucks, a few voices from somewhere in between acknowledging the horror of training and the need for change, but reminding the young ones to remember why we entered this profession in the first place.
2. MD Haters - a few people will then start posting that MDs need to stop whining because our salaries are too high, we all have god complexes, we knew what we were getting into, we drive up health care costs, etc.
3. MD defenders - some people, often nurses, jump the aid of MDs and talk about the high debts we have when finishing, the awful hours in residency, the declining reimbursements, and the difficulty of seeing so many patients in limited time.
4. Lawyers/PhDs - then some other professionals, usually JDs/PhDs start posting about what they go through, how they work 80+ hour weeks/slave in labs and have debts/low wages, are underappreciated professionals too.
5. Some MDs then start to post again whining how the attorneys need to get off this blog because "we save lives" and being a lawyer is never that stressful. They then say the PhDs should go because they do not have the debts we do.
6. Repeat, around and around.

Will the problems ever get solved on the Well Blog? Probably not. But I do think the discussions are good because they give the public some idea of what goes on behind the scenes in health care. And they provide MDs/other health professionals with a virtually anonymous way to voice their feelings, which they often cannot do elsewhere. It can be a lot of negativity, but there has to be a place to let that out if it is not safe to do elsewhere. I think that is one reason why sites like SDN and medical school/resident blogs get traffic. Communal sharing of the pain is one way to deal with it.

Here were a few choice comments from anonymous MDs (not me, thankfully) on the current Well Blog discussion on the residency experience:

I’m currently in my internship and I would love for the next generation to be able to survive their training more healthily than I am.

1. Doctors from before the 80 hour work-week LOVE to hassle this generation for being weak because we don’t have to work more than 80 hours a week or 24 hours in a row. BUT:

It is just not HUMAN to work 24 hours in a row.

For anybody.
I don’t care if you are scooping ice-cream or folding socks, 24 hours is not do-able, the human mind can’t stay sharp, being awake for 24 hours does bad things to your muscles, your digestive tract, your mind, your circulation. As doctors shouldn’t We know this? For gods sake people, I come off a 12 hour shift with leg edema! After 24 hours I want to scream at people even when they are just being people and I’m pretty mild-mannered!

One of the arguments against changing shifts completely every 12 hours, for example, is that there are many details lost in translation between shifts. The ability to communicate succinctly, easily, comfortably are not skills that are valued in the application process to medical school. These skills are in fact underdeveloped in most applicants because we are still pushing those who are ‘good at science’ into this role of physician and unfortunately studying science can be a solitary and unsocial effort. Medical schools and residencies market themselves as looking for well-rounded individuals but they rarely consider anyone with poor scores or grades.

2. Psychology and therapy are not bad words. Why shouldn’t it be mandatory for anyone taking on the job of caring for others to spend time examining themselves, their motives, their influences. Cognitive Behavioral Therapy for example can help with depression, anxiety, perfectionism. If there is ever a group of people I have seen who ALL suffer from these and need some therapy it is medical students.

3. Hospitals are unfortunately extremely unhealthy places. The food for both the staff and the patients is generally low-quality. There is no respect for the act of eating and taking breaks. The only breaks universally accepted are smoking breaks. Wearing scrubs while it is comfortable, I believe, contributes to the normalization of obesity among the staff.
It smells bad. The lighting is depressing. The facilities in community hospitals where much of my training has taken place are deplorable. Why not have intelligent and sensitive and HUMANE architects design the next generations hospitals? With a little aromatherapy, more break areas and areas designed for quiet reflection (who hasn’t hid in the clean utility room to cry when things get overwhelming) hospitals can be less hostile toward those working there and therefore also the patients.

4. The bullying. The elephant in the room in the hospital is the overwhelmingly negative behavior between staff members. It is considered wimpish (and maybe un-American?) to complain about bullying as an adult, but there is an attitude of pouring the negativity that is poured on you onto those below you in the hierarchy. This happens within residency programs, between nurses and doctors, toward the medical students, the aids, the social workers, it is everywhere. How can people who supposedly want to help people treat each other with so much hostility? I think this daily. The culture of negativity and complaining and talking behind people’s backs and criticism without encouragement, etc, etc, creates such a malignant environment that any doctors with a shred of sanity and humanity left opt out leaving behind those who create and harbor the caustic attitudes.

5. I could go on and on but I have another 24 hour shift tomorrow…

---------------------------

Residency turned me from an upbeat, happy, optimistic person into a crabby, ultrasensitive, irritable, depressed and angry person. There are the “80″ hour (my record was 107 hours) work weeks, the “24″ hour shifts (my record was 37 hours straight - without sleep) up to 3 days a week, the condescending and power-hungry attendings who belittle residents and tell them “how easy they have it nowadays”, the average 12-14 hour work-days full of nonstop beeping beepers/paperwork/inability to scarf down a snack or even go to the bathroom without 23 interruptions/and legitimately sick patients, the four days off a month (to pay bills, buy groceries, change the oil, call your parents, and “do all that reading” so you don’t feel like a complete idiot when you’re being pimped at 6 AM the next day in front of 10 other people), the friends who leave you because they “don’t understand why you never call them”, the sheer constant exhaustion that never goes away…

…and you do that for 3-6 years of residency! Of course you get depressed and distressed and hate yourself and the world and that damn patient who comes in in the middle of the night requiring emergency surgery. Of course you very seriously consider dropping out of residency… or life altogether, as a woman in my class attempted to do.

This is NOT a pity party. This is the reality on how doctors are trained.

Until serious and considerable changes are implemented, the smart people will be doing their homework and will take a different career path.

I wish I had.

11 comments:

Kimberly said...

I really enjoy this blog. I've been visiting it for quite a while now. I'm not in the medical field at all, but I just find your thoughts to be really interesting and sometimes very funny.

Resident Anesthesiologist Guy (RAG) said...

I've certainly felt this way several times. Recently it was hitting me hard, wondering why I thought this was the career that I wanted (since I was being pushed around by people all the time, etc) and have thought about quitting here and there. I keep hoping it will be worth it, in the end, but now I'm not so sure. I'd certainly not want my kids to go through this.

The Lone Coyote said...

Kimberly--thank you for reading. I am glad that this blog has appeal to those outside of healthcare.

RAG--I think we all have felt this way at times. It is good to know we are not alone. Will it be worth it? That is the million dollar question I guess...

David said...

Great blog. Your post really hits home. I'm also in my intern year. Today was day #15 since my last off day (though I have been post-call the last two Sundays). What really pisses me off is that this is a consult month and I was hoping to pay down my sleep deficit from the wards.

I know what you mean about getting irritable when you're tired. Saturday night I was on the verge of strangling an obnoxious nurse. Here's a tip all nurses should take to heart -- if you initiate a conversation with a doctor, never lead with the phrase "I don't mean to tell you how to practice medicine but..."

I've also learned the important skill of saying "Give him his sliding scale and recheck his glucose in an hour" without actually waking up.

Also, I've learned there are very few behavioral problems that can't be solved with haldol.

And the patients are a blessing. Sir, I admire your bravery. There are not many patients with 10/10 pain who are able to ravage their food tray with such gusto and ask for more pudding cups (much less do it while watching Monday Night Football). Kudos, you're an inspiring tower of stoicism. Nevertheless, I must again decline your request for discharge with a PICC line and a dilaudid prescription.

Bostonian in NY said...

Medicine is build upon a fastidiously held set traditions. Unfortunately for us, one of them is that that residents are called residents because in the 1800's they lived in the hospital and were available 24/7 to care for their patients. Never mind the fact that they were mostly young men with few interests outside of learning medical practice, smoking opium and cavorting with the nurses (ok so I made up the last two).

Mind you, they were not required to have bachelors degrees, a broad CV full of outside interests/research/life-experience and 4 years of the highly specialized scientific and clinical training...in fact it would be better if they didn't have those things. But then again medicine was much simpler then without antibiotics, the cell theory or a life expectancy beyond 40.

Why won't medical education/residency break from the indentured servitude model no matter how hard we push? Because we are (suckers) selfless individuals who continue to devote the best years of our lives and hundreds of thousands of dollars of higher education for the mere "privilege" of being a physician. And hospitals get paid by the government to (exploit the hell out of) train us, so they will squeeze every last drop of our sanity/youth/well-being out because we have nowhere else to go...

Theresa said...

I just started reading your blog. I have my bachelor's but am going back to school to do my pre-reqs for applying to MD programs. Are there moments where you feel that yes, the hard work is worth it? I have worked in the medical field for about 4 years, but how do you decide if you are up for it? If its worth it?

The Lone Coyote said...

Theresa,

There's no easy answer to that question, unfortunately. Going into medicine is a huge commitment and, at least in the training phase, medicine will take over much of your life. I think you have to weigh what draws you to the field, where you are in life now, and what you have going on in your personal life when making the decision. Best of luck.

brocasarea said...

cant help:(
here we have had 36hrs shifts/60hrs shifts[with 3-4 hrs sleep in between]...unfortunate thing is that except us[docs] no one else have these kinds of inhuman shifts....

Elmo said...

I've been purusing the medical blogoshere alot lately and have seen this trend again and again.

I'm at a point in my life where I may be able to choose either Medicine, or another career path (most likely Health Policy). Reading all of these experiences has made me really re-think my exspectations for medicine and if it is really for me.

You said if you had a choice, you would go back and perhaps do something else. Does this statement still stand now that the emotions/tiredness that may have spurred this blog subsided?

Dragonfly said...

Dude. That was a freaking awesome post.
Re number 2, at times it is easy to lose perspective on things, and you forget that there are people out there who aren't all stressed and negative. Like spending time around the hospital too much and being like "what, people are actually healthy??"

The Lone Coyote said...

Elmo--

This is a response long after you posted. I was going back through old posts and noticed your comments. In the blog entry I was quoting other people who had posted on the Well Blog article on the New York Times. There were a number of posters on that thread who expressed feelings of frustration with medicine, and wonder if they should have done something else.

Personally, I think a lot of us feel that way sometimes, especially during residency when things are really hard. I cannot really answer the question whether it was worth it until residency is over, especially since my residency journey has not been the straight path through that I thought it would be.

I think health policy is very interesting, and I have a friend who has a great career in that area after getting an MPH. There are definitely other paths to careers in health care that require less time for training than getting an MD. I would explore all avenues that interest you and weigh them all when making your decision. Best of luck.