Fighting Moral Decay in Residency

Residency – especially intern year – can be compared to the trenches of war. You are enlisted for a period of time, while you dutifully carry out the orders of superiors, and fight the enemy (disease) while you tend to the already wounded and dying. It removes you from your normal life and can send you into unknown territory, consuming the vast majority of waking hours (sometimes as high as 100-120 hours per week, which is the rarely discussed loophole within the rule of “[no more than] 80 hours per week averaged over a 4-week period”). It can be doubly isolating because the only people who really understand your experience are your compatriots – the co-interns and co-residents fighting in the trenches alongside you. Further, doctors in training, like our veterans, suffer from psychiatric illness and substance abuse issues, but this doesn’t garner much attention unless there is a string of suicides or high-profile articles on the subject. (Time Magazine also ran a story about it in September 2015.)

The onslaught of illness and the specter of disease can be felt throughout the hospital – few places more so than the Oncology wards. I was recently in their team’s workroom and saw that the walls had been covered with motivational and meditative posters. A fellow resident recognized that the last several weeks had been especially tough on the team and decided to find a way to boost morale: (click photos to enlarge)

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What stood out to me most about this sympathetic gesture was the fact that it needed to happen in the first place. Residency is an emotionally and physically challenging experience, but in an environment where there has historically been little support for reflection, debriefing, or physical wellbeing, it’s no surprise to me that the toll can be too much. It’s no surprise that residents develop mental health issues, turn to substance use, or that the experience blunts one’s emotional and ethical intelligence and leads to empathy decline or “moral decay.” (Check out some of this research on the decline of empathy and on the decline of moral reasoning during medical training.)

This is no fault of any one program or hospital – it is systemic. It is also not particular to medicine; the same phenomena can be seen in literature of the nursing profession.

Thankfully, I see signs of recognition that this is a problem, and some programs are leading the way to change the culture – or at least address the deleterious effects. Apart from the updated work-hour rules that changed in 2011 (and whose theories are currently being tested in a randomized program-level cross-over trial called iCompare), some programs are also instituting “Humanities” curricula to support the holistic self – from the emotional to the artistic to the creative – via periodic small-group peer-led sessions. These types of interventional programs have shown some beenfit in increasing empathy in undergraduate medical students.

For example, in some of these sessions, we have protected time to debrief about our time in residency thus far, share the emotions that we have felt (feelings of inadequacy, guilt, sadness, frustration, and uncertainty predominate), and find solace in the commonality of experience. While this curriculum only treats a symptom of the issue and doesn’t make any structural changes to prevent it, it is a welcome measure to nourish the humanity in healthcare and those who provide it.

Other programs are also finding ways to foster longitudinal relationships with patients, which can be difficult while in training, where a medical student or resident will change departments every few weeks. “Continuity clinics” and follow-up interactions allow providers-in-training the ability to establish a connection with a patient and get to know them more as a person than a disease process. The Columbia-Bassett program, of which I am a graduate, and Harvard Medical school’s Cambridge Integrated Clerkship are two examples of this as a dedicated track in medical school, but these efforts are being replicated for students in traditional tracks as well. A great NYTimes article about this trend discusses the ways in which these novel programs are helping allow trainees “to be their fullest selves.”

I would love to see more done to change the culture of hospitals and of residency in general. It can no longer be left up to the individual provider or individual program; the “Physician, heal thyself” mentality must end. A broader recognition of the problem is needed, and a broader recognition of the need to fix it is imperative. An alliance between the medical, nursing, and other affected fields will be critical as we move find better ways to cope with not only the physical demands of healthcare (lack of sleep, regular exercise, and healthy diet) but the mental, emotional, and spiritual ones, too.

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9 comments

  1. “Further, doctors in training, like our veterans, suffer from psychiatric illness and substance abuse issues, but this doesn’t garner much attention unless there is a string of suicides or high-profile articles on the subject.”

    This. Having recently lost someone – a friend and brilliant colleague, who displayed no signs of personal distress and demonstrated nothing but excellence in medical practice until the last – to suicide, I posted an article about physician mental health issues on my Facebook page. I was so disheartened (and, in all honesty, floored) when two non-medical friends – PhD friends I’d worked alongside (and HELPED) in grad school – felt the need to poke fun at the sentiment therein. ‘Lol-ing’ about the “whiny, overpaid doctors” interviewed in the piece, writing that “other people struggle to put food on the table and these people with hefty salaries are lobbying for free hugs,” stating that “people without strong constitutions and long bootstraps shouldn’t be allowed to be doctors,” and expressing the opinion that their “doctor better buck up if he wants his copay,” they each left long, feisty screeds on my wall. I came (calmly) right back at them with information about physician training, lifestyle and burn out and, more importantly, about mental illness as a disease/chemical imbalance with genetic and environmental triggers, NOT a character or constitutional weakness or (shudder) a choice. I had plenty of back up from other physician friends and acquaintances on the post, but the stigma regarding mental illness – and especially physician mental illness – unmasked in the discussion turned my stomach. I hope that these issues will be better addressed as we continue to demand more from life than excellence of medical practice… Thanks for a great post.

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  2. This is such an important topic that needs to be talked about more. There’s an awesome book called “Trauma Stewardship” by Van Dernoot Lipsky that I would be happy to read to you while you are napping or something! Keep fighting the good fight. Love, Clare

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  3. I come from a family of medical professionals (9 docs, 3 nurses) so I’m all too familiar with these issues. It saddens me that those that work so hard to care for their patients often take the worst care of themselves and those that work alongside. I cannot tell you the number of times I’ve heard ‘well, we managed’ and I want to shout yes, but wouldn’t you have been all the better if you didn’t have to? Wouldn’t it have been better that you established those habits that might have allowed YOU to live the healthier life that you eschew? As you continue on your path, remember that you, too, are important and take care of yourself. Only when you make that a priority can you do your best work in taking care of others. Good wishes to you, doc.

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  4. Having trained as a doctor in England I can assure you this is an international scourge. I experienced it again when I came to the US and did residency at SUNY at Stony Brook. Everyone was reading House of God by Samuel Shem, with his cynical but accurate portrayal of the hellish life of a resident – which I talk about in my book Managing Your Doctor – The Smart Patient’s Guide to Getting Effective Affordable Healthcare and at my website Managingyourdoctor.com

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