“He saw that he really must get well, he couldn’t go on this way … He sank back in his chair and agreed at least to that: his business for the rest of the month was to get ready to be ready to be well.”
—Edward St. Aubyn, Some Hope
When I took a job as a residency coordinator in graduate medical education at a local community hospital, I made myself a promise: I will not date a resident. They’re too busy, we work together, and we have nothing in common.
I held out for four years. It’s hard not to fall in love with the people you’re surrounded by every day, eccentricities notwithstanding. I held various resident-facing roles in the department, a centralized GME that administered all eight of the hospital’s residency programs, and I ran the simulation lab. The residents and I were the same age: they were smart and engaged; I was social and insightful, just far enough inside their world to understand it, but far enough outside not to be consumed by it. Soon some of them became dear friends.
My now-partner, Evan, was one of the quiet ones. I don’t think I’d ever heard him speak until halfway through residency, when I found myself at his 30th birthday party at a nearby bar-slash-bowling-alley, dragged along by a resident friend of mine in his class. He was sloshed to the gills that night, but funny and clever and open. We talked, pressed against the sticky bar, and he spent the next week haunting my office. That was two years ago.
I’ve written about the vicissitudes of resident life before, but that was before Evan. That was before I spent two years in the intimate company of a proverbial soldier on the front lines. I had seen it all during my GME tenure, among resident friends and acquaintances — divorce, depression, substance misuse and abuse, expulsion from residency for reasons dubious and legitimate — but I hadn’t lived it quite that close up, nose pressed against the glass of one person’s quotidian existence.
It is exquisitely painful to watch the person you love get broken by their job, destroyed by the thing they once loved. You get your heart broken every day they come home with a story of a wrong medical decision, theirs or another’s. When they work so many hours in a week they forget what month it is. Every time a busy attending abandons a research project they’ve spent dozens of hours on, or flakes on a letter of recommendation. When their vacation request, the one week a year that lines up with your work schedule, is denied due to hospital staffing needs. It isn’t the time apart you resent. It’s the pieces residency chips away, the way your partner wakes up every morning with a few cells that cared yesterday, but don’t today.
What’s worse is that you can’t tell your partner how painful it is, because their heartbreak is primary, yours necessarily secondary, because they shouldn’t have to bear that burden on top of everything else. You want to tell them it’s all worth it, the time and debt and humiliation, but you also don’t want to lie. Your partner, the resident, lives at the center of the relationship because their needs and deficits are always and dramatically greater than yours. You can try to keep up with them but you will never be as productive as residency is destructive. Your love can never equal its inhumanity. All this does not add up to a martyrdom, but it’s not nothing, either.
When you work in medical education, you can hardly go a day without hearing the word “wellness.” You hear it so often that you start to wonder what it means. To figure this out, you must first ask yourself: From whose lips does this word fall? The answer is: almost exclusively hospital administrators, residency leadership and the Accreditation Council for Graduate Medical Education, the national body that governs residency programs. Among these groups, “wellness” has become a kind of shibboleth that indicates an awareness of the horrors of resident life accompanied by a total indifference to them. “Wellness” is admin-speak for, “Stay just sane enough to continue providing indentured labor for the hospital.” I assure you, you don’t hear actual residents saying “wellness” in any non-ironic tone — because they know they are being condescended to, dealt with, managed. Residents are not stupid. But they are tired, and vulnerable, and few have the energy reserves or professional security to speak truth to power.
What is wellness, anyway? Is it the absence or mitigation of distress, or a positive quality? Are any of us well in this diseased era? At the broadest level, residents are fellow casualties of the shattering — and intentional — misallocation of resources that defines late capitalism. We are all poorly, and they are poorly in their own particular way. Society’s compassion for the suffering of vulnerable groups often fails to extend to residents, because of the high earning potential on which they are nearly guaranteed to deliver, and because residents have been taught, above all, never to complain publicly.
But here’s the thing about residency: It breaks people and they stay broken. Attending-dom is not a magical land where the traumas of medical training evaporate in the glow of better pay and an easier schedule. They are stifled, or acted out in personal and professional relationships, and those who would harness painful memories of their own training to create a kinder future for young physicians quickly find themselves buried in the stressors and responsibilities of the job. Despite their best intentions, doctors flame out in the service of healing others.
If we are to heal medical education, we might start by affirming what wellness is not. Wellness is not a yoga class, or a coffee cart or a meditation practice. To be well is not such low-hanging fruit. If the modern age is the age of interiority, then perhaps we have gone too far in locating the sources of our unhappiness in our own minds. Practices like mindfulness and gratitude and other forms of yuppie “self-care” are generally benign unless and until they obscure the material causes of people’s suffering. No amount of meditation will compensate for not having nutritious food to eat, time to sleep or emotional bandwidth to spend on one’s loved ones. Insofar as scientists have studied happiness, most notably in the Harvard longitudinal study, they have identified interpersonal connection as the sine qua non of fulfillment. But how are you supposed to connect with your friends, partner, family, if you can’t stay awake long enough to hold a conversation?
This obvious truth eluded me until Evan did his trauma ICU rotation at the county hospital in his third year, on which he took 30-hour call every four nights. He found the hospital cafeteria food inedible, so I brought him dinner every call shift. I cleaned his apartment and bought groceries, massaged him to sleep and ignored his abruptness. None of it mattered. He was only half a person, and that half belonged to the TICU. When he finished the rotation and regained a more normal sleep pattern, I thought, “Oh, my boyfriend isn’t an asshole after all. He was just very, very tired.”
But eventually the tiredness adheres to a person like a slime. Fatigue is a King Midas that turns everything it touches to shit. Fatigue comprises not only the physical and mental exhaustion of long hours and sleep deprivation, but also the dehumanization medical trainees endure from almost everyone they work with: administrators, nurses, senior residents, attendings, even peers. Abuse, subtle and overt, is the lingua franca of residency. Willful inattention to the personhood of trainees makes the abuse palatable. Would you mock someone you just met on the street for needing to drink some water, or take a sick day? One of my dearest friends, a surgery resident, left the operating room briefly to vomit due to a viral illness. Upon her return, the attending scolded her for missing critical portions of the case.
The obvious question you may be asking is: Why do you still work in medical education if it’s so toxic? I don’t have a wholly reassuring answer. I can tell you the quiet moments in the interstices of patient care and paperwork have been the best of my job: the resident stopping in my office for a quick vent between cases, or a distraction from a day of small irritations and banalities. I love stories and medicine is a gold-bearing vein (no pun intended). The practice of medicine is fundamentally narrative. Doctors enter complex, individual stories at critical junctures, speed-read the cliff notes and do what they can to ensure the tale goes on. Residents, still relatively early in their training, allow themselves intimacy with their patients’ histories and journeys. They feel every rushed appointment, every missed IV. That early-career permeability is precious.
But having lived alongside it for so long has left with me with a sick feeling, a mere residue of the resigned anger I see in Evan’s eyes every night. In them I see the childlike rage of someone trapped in the gears of a behemoth system that turn without sympathy or notice. These are the same gears that led his father, also a physician, to early retirement, and my mother to pursue a second residency and finally a withdrawal from clinical medicine entirely.
The long legacy of a corrupt system does not justify that system. This series is for all those who are ready for what comes next. I’ll be discussing physician wellness without mincing words or protecting delicate feelings. My aim is threefold: to dismantle the assumptions that underlie discourse around resident life and impede real change; to tease out the material factors that undermine wellness; and to suggest directions for the future of medical training (and the practice of medicine more broadly). Stay tuned.
Please read Part 2 and Part 3 of this three-part series.
Image credit: “Copy Paper” by Dean Hochman is licensed under CC BY 2.0.