Monday, February 1, 2016

Medical training

"Med school completely destroyed my self-confidence," one doctor-to-be wrote. "I am constantly feeling stupid and worried about failing out."

Hers is one of many recollections recounted by family physician Pamela L. Wible, MD, who hosts physician retreats on career reclamation, in a recent Medscape article. To better understand what happens, Dr Wible surveyed 189 medical students. "I asked them to answer one multiple-choice question: 'How has medical school impacted your overall self-confidence and/or self-esteem?' Of the respondents, 42% reported an increase, 50% reported a decrease, and 8% noted no change. Medical students were then encouraged to share why."...

But for most respondents, the culprits were abusive preceptors, attendings, and fellow residents.

"I entered medical school so very confident in myself, and that was beaten out of me," one medical student confessed. "I was repeatedly told I was stupid."

"I had emotional whiplash in residency," a family doctor remembered. "Attendings would gang up on one resident and say, 'You're destined to fail. You're lazy.' I received scathing reviews about 'attitude' and 'difficulty with authority.' I remember standing in my bedroom having crazy panic attacks and thinking I could not go on."...

"Our program director suggested we get 'slave' T-shirts for the group," an internist confided to Dr Wible. "In my residency mailbox, I even received nasty anonymous 'you're too fat' notes, with ads for diet pills attached."

"Of those who reported a decrease in self-confidence, their experiences often led to chronic mental health issues, including PTSD [post-traumatic stress disorder]," Dr Wible writes. To rectify such abusive situations, she makes the following recommendations in her article:
  • Stop institutional abuse (she urges medical students and residents to report it and stand up to it);
  • Seek mental healthcare (many doctors say they are depressed or anxious as a result of mistreatment; some are suicidal);
  • Build strong relationships (supportive relationships can help you through rough spots, Dr Wible advises);
  • Promote a culture of open communication and respect; and
  • Refuse to be a victim.
The article elicited scores of responses from physicians, the majority of whom recalled their own abuse in medical school, residency, and beyond, confirming Dr Wible's assertion that such confidence-eroding abuse is widespread in medicine.

"It has been a hard journey," a cardiothoracic surgeon agreed. "My medical school did nothing when I informed them of sexual harassment by a professor. I was told to take him out for a cup of coffee and let it go. One of the surgery professors discouraged me from pursuing surgery because he did not believe it was for women. Afterward, during job interviews, I was asked when I planned on becoming pregnant 'because you are attractive, and I fully expect you to start a family.' Or: 'You are attractive. Are you sure you know what you are doing?'"

"A surgeon recently talked about how he didn't even know he was a jerk until his hospital instituted a 360° feedback policy from all his coworkers," a psychiatrist observed. "He thought he was just behaving the way he was trained to do in residency. For decades, he treated every nurse, tech, resident, and med student like they were subhuman. Now, think of all of the other surgeons he did his residency with who have never gotten any feedback. They are all out there right now, treating everyone around them like garbage."

"As an academic for 10 years, I witnessed the bullying, insults, and demeaning attitude toward students and residents," an anesthesiologist confessed. "The culture is self-perpetuating and ingrained. Unless medical schools make a major concerted effort to change the toxic milieu, nothing will change."
"This article hits the nail on the head," a physician wrote. "I hope the medical community sits up and takes notice. Physicians are humans who feel, live, and breathe and must be healthy to keep our patients healthy. But many become emotionally crippled by medical school and residency. Nobody sits up and takes notice until someone becomes a victim of suicide, and even then, the blame is entirely placed on that individual. It is just so wrong."

"Thank you for starting a dialogue on medicine's dark secret," a general practitioner commented. "More light needs to be shed on the insidious and overt nature of sexism in the male-dominated/better-paid areas of medicine. In my experience, this manifested as everything from being socially isolated and shunned, to being placed under the microscope when the male doctors in my residency program were not, to being told that maybe I was smart and beautiful, but I was not doctor material. Maybe I should become a porn star instead."...

"I'm not trying to sound macho," an oncologist opined, "but I still feel that having tough med school/residency experience helps to weed out the wheat from chaff. Even if we make the programs more humanizing, some weak souls will drop out, as they are not cut out for this profession."

"It's unfortunate for those who enter medicine if they couldn't handle it," an emergency physician agreed. "It's sad that PTSD, depression, suicide, broken marriages, and drug/alcohol abuse occur from these unavoidable pressures. It's a shame if you feel that you wasted your 20s and early 30s buried under an avalanche of preparation and humiliation. But this is the course we set. It is the burden that we must bear. It is why becoming a physician is NOT a career."
"What a sad view of our profession," a family physician noted. "I guess I was lucky. At the medical center where I trained, the program was supportive and encouraging. I experienced some pretty awful surgical residents during surgery rotations, but this only lasted for a few months. I am sorry for the terrible experiences you have all endured. Your training should not have been like that."


  1. I was talking to Regnal Jones recently about the Chicago Area Health and Medical Careers Program, where he's been executive director since 1985 and has helped nearly 5,000 students from underrepresented racial and socioeconomic groups enter the health professions.

    The Illinois Institute of Technology-based program is one of the most successful and comprehensive academic efforts of its kind in the country. So imagine my surprise when Jones, a University of Chicago-trained molecular geneticist, told me he no longer recommends that his students, many of whom arrive as high school juniors, pursue a career as a physician.

    On the day we talked, a former student, who's now a physician assistant, had come to his home asking for advice regarding whether he should return to school to become a doctor.

    "I told him that I don't encourage anybody to go to medical school," Jones said. "Nobody I care about."

    I paused.

    "Does that surprise you?" he asked me.

    It did.

    "The cost is too great, and it's a lousy job," he said. "The minute you say to me that you want to be a physician, it's tantamount to saying you want to be an indentured servant."(continued)

  2. (continued)Jones said he feels so strongly in part because medical school tuition can cost hundreds of thousands of dollars, and the time investment, depending on whether the student wants, for example, to be an internist or surgeon or orthopedist, can consume years of his or her life.

    "Then after medical school, you're working 80 to 100 hours a week for about $40,000 a year as a resident," Jones said.

    Residencies are usually three to seven years, depending on the specialty.

    "Most people think physicians overwhelmingly are rich," he said. "But many of them are saddled with an enormous debt load that takes years to repay. Some never make up the ground."

    Jones said another major problem is that there are fewer places for students to do their residencies. In February, the American Medical Association asked Congress to retain Medicare funding for residency programs and increase the limit on the number of available residency slots to address a shortage of doctors.

    Last spring, about 900 U.S. medical students weren't matched to a residency.

    And, yet, the number of students graduating from medical schools has grown steadily. The Association of American Medical Colleges says that a decade ago, there were 15,531 graduates from U.S. medical schools. In 2012, there were 17,341 graduates.

    "You have to do a residency to get a license," Jones said. "There are fewer residency slots available to finish your training today than in 1975. It's a regular supply and demand issue. And hospitals get to pay people what they want and work you however they want."

    There has been a lot of talk about the need for more doctors, particularly in light of the health care overhaul. I asked Jones whether the Affordable Care Act, which is expected to bring an estimated 30 million more patients into the health care system, changes his perspective regarding medical school as an option for his students.

    He said it doesn't. Although the health care system will need to be revamped in many ways, he believes that physician assistants and advanced practice nurses will help take up the slack. Over the last decade, the number of physician assistants has more than doubled to about 93,000 today, according to the American Academy of Physician Assistants, which expects the number to continue to rise dramatically.

    Jones said this is a good alternative for students who love medicine and want to help heal people.

    "Many physician assistants already do what physicians do and, in some cases, do it better," Jones said. "Their patient outcomes can be better and they go to school for fewer years and don't do residencies or have the same debt. A lot of them don't even need to consult with anyone to manage care."

  3. For every physician who reports a decline in self-esteem and/or self-confidence in medical training, another reports an increase. What's the secret to thriving in medical school? Just getting into medical school is a confidence builder. After graduating med school, many physicians feel they can survive anything.

    Physicians fared best in progressive schools that promoted student well-being and medical humanities. Some doctors strategically avoided certain specialties. "I had a sense of self-preservation and avoided the specialties where I observed residents being routinely abused and dehumanized," Wayne shares. "I was attracted to psychiatry by the attending staff that exhibited a more holistic and gentle approach to patient care. I escaped residency unscathed emotionally and gained a lot of insight into my own blind spots. My self-esteem and confidence were certainly bolstered by my medical training."

    Having a good support system strengthens students' self-worth. "I had a great core group of friends in my residency and a very supportive group of attending physicians. We helped each other and always made time for fun," shares Paul, an internist.

    A welcoming atmosphere of mutual respect and open communication positively affects self-worth."My medical school was wonderful," Rochelle says. "We were called 'young doctors' and generally allowed to question things. We were encouraged to report harassment and they told us, 'You are all the brightest and the best and you are going to go on to amazing things.'"

    Linda, a family physician, reports, "I think self-esteem is a more fundamental issue that is pretty set once you've reached med school and residency. My self-esteem is generally good, which is why I refuse to put up with this abusive medical system. I don't let other people abuse me and I won't allow this broken system to abuse me either."

  4. Though many medical students and physicians experience enhanced self-confidence and/or self-esteem, our medical education system injures nearly half of our nation's medical students and physicians—many with lifelong sequelae. From my own research, 38% of practicing physicians report that working in the American healthcare system has harmed their self-confidence. Here's how doctors can protect themselves and their colleagues and help the next generation of physicians.

    1. Stop institutional abuse. Sexism, racism, and bullying should be never-events in our healthcare facilities. Witness abuse? Report it. Stand up for yourself, your colleagues, and patients. Ban fear-based teaching methods. Remove abusive professors from teaching positions and offer remediation. Medical students should be protected, not injured, by our healthcare institutions.

    2. Seek mental health care. All medical facilities should have on-site mental health services for health professionals. Medical students and physicians shouldn't be punished for seeking healthcare. Doctors should be encouraged to grieve and offered a safe place to do so at work. We must receive the care we are expected to provide to our patients.

    3. Build strong relationships. Maintain supportive relationships with friends and family. Befriend physicians. Be a mentor. Remember: The foundation of healthcare is the sacred patient-physician relationship.

    4. Promote a culture of open communication and respect. Vulnerability and authenticity should be welcomed in medicine. Encourage open discussion, self-doubt, and self-discovery. Honor individuality. Respect each other. Nurture medical students. Inspire them to remain in medicine, stay alive, and live with empowerment and purpose.

    5. Refuse to be a victim. Although my medical training was dehumanizing and I was undervalued by my employers, my self-confidence ultimately increased in both medical school and in the practice of medicine. Surviving the inhumanity strengthened me. Not everyone survives. But I prevailed because I refused to be a victim. I encourage my peers to do the same.