Please read Part 1 of this three-part series.
“Peace is only better than war if peace is not hell too.”
–Walker Percy, The Second Coming
My partner Evan’s third year of residency completed his trajectory toward what is commonly called “burnout.” Two out of the 10 residents in his class left the program. In an already understaffed department, the remaining residents picked up the slack, taking extra call and working longer days. The general misery index among his cohort skyrocketed.
I don’t mind the term burnout as much as others, because it sounds like what it means: a flame once proud and furious gone down to embers. I have watched loved ones combust in this way, the fire of their resentment and shame consuming them until the human underneath was barely perceptible. That year consumed Evan. “I’m 100 percent done with that place,” he would say, arriving home at 11 p.m., shattered. “I’m just going to put my head down and get through this.”
I didn’t try to argue or assuage. I was angry, too. The hospital to which Evan gave the lion’s share of his time, his unflagging conscientiousness, his attention to minute aspects of the patient experience, rewarded him by grinding his nose into the dirt.
A month or two after these resident departures, Evan’s program called a meeting between the residents and the hospital’s DIO (Designated Institutional Official, the physician head of graduate medical education), the Administrative Director of Graduate Medical Education (an impressively disengaged paper pusher), and the hospital Vice President who oversaw graduate medical education (who once asked me how long medical school lasted). The DIO, a latter middle-aged immunologist, stood at the front of the windowless gray conference room and addressed Evan and his peers, who had not, prior to this meeting, received any communication from leadership about the program’s alarming and sudden attrition.
Why, according to the DIO, were they hemorrhaging residents?
“I think it’s partly a millennial issue,” she said, to a room of millennials. “Millennials are just not as tough. They’re used to getting what they want.”
“Part of the issue,” she went on, “may lie in our recruitment strategy. How do you think we can recruit better people?”
Better people. Better people. It’s been over a year, and I still want to know what she meant by those two little words. People immune to mental illness? People incapable of making a mistake? People without personalities, or lives outside the hospital? People who would never question the lot they had been dealt, or the inequities of the system in which they worked? Or maybe just people who wouldn’t cause a stir, ask complicated questions, make her life harder. I won’t ever know, and I won’t ever ask. But deep down I know. We all know.
In my research, I discovered programs that boast of having solved the wellness problem. Wow! I thought. That’s incredible!
Most institutions that make such a claim, it turns out, have implemented a three-pronged strategy. First, they convene a wellness committee, that perfunctory gesture toward Doing Something. The function of the Resident Wellness Committee is entirely cosmetic. Usually composed of residents with no protected time to sit on a committee, and administrators with no personal investment in real action, the committee bandies about feel-good-isms about gratitude and self-awareness until the residents are so bored and frustrated they consign the whole dismal experience to a line on their CVs.
Second, programs offer the occasional lecture on wellness, invariably at 6 a.m., when learners are at their emotional and intellectual peak.
And third, they plan group bonding activities. This last method is aimed at fostering what wellness advocates call “resilience.” Resilience, broadly defined, is the ability to recover from setbacks. In the GME world, resilience is an ineffable quality that can be cultivated by hiking, or joining a book club, or something.
Maybe petting a corgi can heal the emotional strain of a flat tire, or an annoying conversation with a parent. But it’s not going to do much for years of overwork and abuse. Suggesting a resident devote some time to reconnect with his passion for ornithology is like telling a homeless person to take a nice spa day. It doesn’t address the root problem, and in any case, he can’t.
Perhaps the best-meant wellness measure I have seen enacted is free and unlimited counseling for residents and fellows. But this superficially generous offering rests on the assumption that the answer to the trauma wrought by residency is damage control, rather than structural change. Don’t mistake me; as a New York Jew, I believe literally everyone should be in therapy at all times. Yet how trainees are supposed to make time to go remains a mystery. As with health care more broadly, granting residents “access” to counseling does not mean it is actually available to them.
No matter the specifics, the officially-endorsed solution to unwellness is always: “Do more.” But do more is literally the last advice anyone should be giving residents. Adding commitments to a resident’s calendar will never be the answer (unless you are reducing their clinical duties to compensate). Residents are already too busy, and they already spend too much time in the hospital. Our compulsively busy society radically undervalues idleness, to its own detriment. When Evan tells me he feels guilty for spending a Saturday sitting on the couch in his underwear, I tell him there are plenty of things in this life to feel guilty about — hurting others, violating one’s moral principles — but the pleasures of an empty day are not among them.
In medical training, resilience might be defined as “the capacity to detach so completely from one’s emotions that insults great and small roll off like water.” How else can anyone withstand the demands of residency and stay sane? Unfortunately, the qualities that enable a person to survive are generally inimical to those that would help him thrive. When you refuse to feel what happens to you at work, you stop feeling what happens to you anywhere. You slough off anything inessential. The actual substance of your life dissolves like powdered sugar. At the same time, heightened vulnerability turns a pinprick into a death wound; a single bad grade or breakup is enough to cast you into total despair.
Of course, the real elements of resilience are simple: food, sleep, shelter, meaning, human intimacy. But the wellness discourse’s unerring tendency to place the onus of health on the trainee intentionally obscures the systemic causes of resident suffering. Wellness becomes a matter not of power and injustice, but of personal failure and responsibility.
The sources of hardship among physicians are complex and manifold, but one fact stands solid and undeniable as a monolith: residents work too much. To health care administrators, the overwhelming salient fact about residents is that they come cheap. To borrow a term from feminist theory, the labor of residents is “infinitely elastic”; it can stretch and stretch, within hazy limits, to accommodate the needs of the hospital. Unlike techs, nurses, nurse anesthetists, and other providers whose contracts (or unions) strictly define their work hours and conditions, residents face a near total lack of protection against and recourse for wrongs committed against them. They work in the proverbial factory floor with the windows closed in 98-degree weather. If you think I’m exaggerating, talk to a resident who’s passed out from hypoglycemia after a day without a food break.
The concept of a medical residency was born about a century and a quarter ago at Johns Hopkins, that notoriously happy institution. Back then it was optional, unregulated, and, needless to say, entirely white and male. By the 1970s, trainees were burnt out and debt-ridden. Workload, specialization, and impediments to direct patient care had surged. In the 90s, the rise of the now-ubiquitous electronic medical record sealed the fate of the one-man physician-cowboy who, until lately, had largely determined the conditions of his working life.
We will never return to that era, nor should we want to. HIPAA; quality controls; population medicine; IRB protections of human research subjects: these are all to be heralded, and when elder docs stand athwart history, yelling Stop, the word “Tuskegee” springs to mind. Medicine as theory and practice has transmuted irrevocably, even in the last 20 years. But instead of reimagining the training of new doctors to suit a changed profession, we have chosen to bend human beings into increasingly deformed shapes to fit an archaic mold. Medicine eats its young.
Yet the history of residency is not without incremental improvement. Proponents of reducing resident workload hailed the Libby Zion Law as the next coming. Passed in New York State after a patient died due to alleged resident overwork and lack of supervision, then adopted by the ACGME in 2003, the regulation limited trainee work hours to 80 hours per week.
But the raw truth is that 80 hours is still far too many to work in a week. Twelve hours means a short workday for Evan. Working a 12-hour day renders me, on the other hand, totally incapable of feeding myself or making conversation or really engaging in any meaningful human endeavor. It’s irrelevant that in the bad old days doctors-in-training used to work 120 hours a week. Their working conditions were unrecognizably different, and anyway — what kind of lunatic is nostalgic for this way of life? My own father fell asleep at the wheel twice during residency.
The old guard regularly trots out its golden calves to justify the misery of residents: the bond between patients and their doctors. Continuity of care. The dangers of adopting a “shift mentality.” To this parade of idols I reply: Who cares? The lives of doctors are not worth less than those of their patients. And it is doctors’ very lives that are at stake. To cling to the current system of medical education (and medical practice) is to deem acceptable the astronomical rates of burnout, mental illness, addiction and suicide that plague physicians. I do not accept this.