When I was a resident, prior to contract renewal, I had to complete an online "education session" on depression.
They had a little scenario where a resident is presenting a patient and fumbles a little, resulting in getting completely reamed by the attending who says something like, "Hello? Anybody home?" Then resident bursts into tears, says, "I'm sorry, I can't do this anymore!" And dramatically runs off.
I'm not sure if that was supposed to be the "bad" scenario or simply the most realistic one.
In the second scenario, the attending is a little more understanding and talks to the resident privately after rounds about her recent decline in performance. The resident says that she's having some problems with her husband and the stress of work is too overwhelming. And she reveals that when her husband took her twins (!) out for ice cream the other night, she stayed behind and just cried. Then the attending asked her if she'd ever thought of hurting herself and she replied no, but that she sometimes thought she'd be better off dead.
What struck me about this exercise was how realistic the first scenario was compared with the second. If you, as a resident, fumble, most of the time the attending isn't going to sit you down and have a heart to heart. You're going to get reamed.
(I'm not sure why they were showing this to us anyway, considering we were residents. What were we supposed to do about this? Wish vehemently for Attending #2?)
The truth is, if you're at all inclined to get depressed, medical training is going to bring it out in you. Especially intern year. Interns have it really hard--you pretty much get dumped on by everyone and you're constantly exhausted. In retrospect, that was possibly the worst year of my life.
I personally know two interns who attempted suicide, one of whom succeeded. It's really horrible when someone you know does that, and it's hard not to get really angry at the culture that nurtures it. The culture of med school and residency is that when you start to struggle, things get infinitely worse. In the several programs that I attended, there were no resources readily available for trainees who were struggling.
I don't think the culture of medical training is going to change. It's not realistic to think the old school attendings are going to stop making interns cry. But I think having some mandatory (or at least very easily accessible) counseling might improve things. I don't think half-hearted group "wellness" meetings that get canceled half the time are really cutting it.
Some hospitals have chaplain services open to staff and residents. Perhaps that is a resource???? (Although it doesn't really make attendings more sympathetic.)ReplyDelete
All this really makes me wonder about the good this does patients. As a chronic patient, I feel like most of us suffer through a lot of craziness in order to get to the point where we need to see a physician. If physicians can't be sympathetic with their own kind, will it even cross their mind to empathize with their patients?
I have never once met a staff member who used chaplain services... usually just patients use it. And it may not be religiously appropriate.Delete
You're absolutely right. A bigger change ought to happen, both for the sake of medical professionals and also for the benefit of those they ultimately care for.
I think the scenario that I'm thinking of was a religiously-affiliated hospital tied to a pretty big theology school. The upside is that chaplains will not report stuff to your attendings(!!) but the downside is that I think most medical professionals shy away from religion for that type of thing....
I wonder, too, if it has to do with the fact that patients are much more receptive to the fact that life is mortal. Hmmm, maybe a topic for another time.
Thanks for your intriguing post. :)
Unfortunately when you train, you are surrounded (it seems like)by hostility. Nurses pick on you, cleaning staff tries to frown when you walk down the hall (as if you walked too close or on a freshly cleaned floor), every person on your team is comepting with you, and attendings make it their job to humiliate you. I just do not remeber anybody who was "supporting" in one of my training programs. Luckily in another we had a fabulous program director. Multitasking is taken to such a level, that even in your sleep you are supposed to be working and making life and death decisions. One of my colleages was on call and had a dream about a patient coding on the floor. He jumped out of bed, rounded up his team and climbed 2-3 flights of stairs to that patient's room to realize that it was only a dream. Its very importan to keep your own physical and emotional state in shape. Exercise, sleep, eat regularly (that is sometimes harder than the first two), avoid socializing so it does not interfere with first three. Because you do not have time for everything.ReplyDelete
I was the resident in scenario #1 just a few weeks ago...minus the husband and the twins and all. A lot of the "old-school" attendings can be very unsupportive and can make things really miserable for residents who are struggling. That being said, I've also worked with many senior residents and attendings who are very supportive and make life easier. I think it depends a lot on personality and the environment in which they were trained, as attendings tend to do unto others what was done unto them.ReplyDelete
I think there is some change happening in the culture of medicine though. At my school, there is a free counseling service that is readily available to medical students or residents, and we're encouraged to use it if we need it. As well, many of the younger attendings are starting to recognize the importance of mental health/personal well being and to encourage trainees to take care of themselves. Changing the system will be slow, but it isn't impossible.
I can't really speak to medical training, per se, but I think that an additional factor for that sort of situation is that, in this country, mental illness is so poorly understood. Concurrent with that is the difficulty, in general, for getting treatment for mental health issues. There are far too many people, educated as well as lay persons, who are too ready to assume that there is a bistable condition for mental health: either one is mentally healthy, or one is mentally ill - and thus at risk of whatever ill behavior has been in the news lately. (I've been following the news of the legal wrangling for the man who set the fire on the USS Miami.) With that kind of attitude, becoming known to have sought out mental health treatment or support can become an additional stressor, or worse, an active risk to one's career goals.ReplyDelete
I guess what I'm trying to say is that even if the resources become more available, without a change in the way that people, including doctors, view mental health, that's only going to be merest tip of the iceberg.
Yeah, I agree this is a huge issue. Physicians in general, especially female physicians, have a higher rate of suicide completion than the general public. It's unfortunate that the culture of medicine isn't really taking this seriously and changing, or is changing very slowly. Luckily, at my school (just like Solitary Diner's), we have free and accessible counseling for medical students (and residents?). I know I've had to use it a few times... lolReplyDelete
Hopefully wherever I end up for intern year has counseling! haha!
So... I think in general the world would be a much better, happier place if people took the time to be more understanding of one another, and didn't pounce on opportunities to beat each other up.ReplyDelete
That said, finding an work environment like that is really asking a lot. The best you can do is try to find somewhere that you fit, and that doesn't make you feel like that with any sort of frequency. I don't think I've ever worked with ANYONE who would do what the attending in scenario B did, and I'm not sure I'd want them to anyway. Neither my boss or my colleagues need to know about my personal life or my internal struggles. They're just going to file that shit with HR anyway, and use it against you later (at least that's how it would work in a company outside of medicine).
The world's a rough, shitty place. Doctors especially treat each other like garbage, though this is certainly not unique to medicine. The best way to end it is to not act like that yourself. When people act like that towards you, try (and I am not good at this) not to personalize it. Think to yourself, "His wife probably screamed at him this morning, that's why he's acting this way." Maybe it's even true.
"The world's a rough, shitty place. [Working environments, where people] treat each other like garbage...is certainly not unique to medicine."Delete
Oh man, OMDG, you couldn't be more right. I used to work at a lab where the lab tech would pounce on everyone every chance he got. He cussed the shit out of a pregnant grad student. He yelled at many undergrads and scared them off from research. I personally cried twice during the time I worked there because he treated me (and everyone) like you had a peanut for a brain. And, he reeked of cigarettes smoke. He'd also slam drawers bull of beakers on an average day.
You just gotta learn to deal with it.
I'm a little in agreement with OMDG...when I started my fellowship, I got off on the wrong foot with some (Ok, one) of the (high-power) attendings, and they (he) thought maybe I was "struggling" with something. The fellowship director (a sweet young-ish attending) sat me down to talk about what could be affecting my work performance...I happened to mention, at her prodding, that I was a little worried about my husband not having a job (we moved up here for my program, and it took him several months to find work), and don't you know, my personal business got talked about at the faculty meeting (I heard about this much later from one of the junior attendings who I became friends with). Last time I ever EVER mentioned being worried or "struggling" or not 100% on top of my shit to anyone superior to me at work. The general culture is not to "help", its to use against you.ReplyDelete
On the other side, I did get really depressed intern year after a needlestick incident with a HIV/Hep C positive patient. I did see a psychologist through occupational health & there was free counseling available to all residents & med students through our school, but I honestly didn't feel I had the time to take advantage of it (this was pre- any kind of work hour restriction). So the resources were there, but the culture was such that they were practically useless....
OMDG - yours are some pearls of wisdom. Its great to have this analysis of things going into stressful field. I think for most unseasoned youngsters (myself including at the time) take it personally. I thinks it would help more if orientation cinludes some sort of stress prophylaxis. Rather than dealing with bad things later in the training, its good to have the right mindset fomr day one. Because you can really tell that some people you work with clearly have their own insecurity issues or personall struggles.ReplyDelete
One of your blog locations changed, it's now http://www.skepticalob.com/ from whatever it was before, and the new posts don't update, obviously, on your blog list.ReplyDelete
This is a subject that personally touched me and my husband. We lost a brilliant young surgeon and friend. I wrote about it earlier this year: http://www.yourdoctorswife.com/2012/02/losing-leo-when-resident-decides-to.htmlReplyDelete
Sorry to post the link, but is still very raw and I'd rather do that then rewrite a summary. It was so incredibly shocking, sad, and senseless.
Touching post, I'm glad you posted the link. What a waste.Delete
This is why I didn't go to med school. I'm already seeing a psych and I'm doing Radiation Therapy, imagine if it was med school!? Shit sticks!ReplyDelete
I've struggled with depression and attempted suicide in the past before. I'm a little afraid of MS3/4 and residency...this is why I've eliminated any surgical or IM field from consideration haha. Hopefully I end up in a place that has counseling resources.ReplyDelete
I love reading your blog simply because sometimes, I feel like I'm less alone in the way I feel. Like this entry. Man I've been having a terrible time lately and sometimes I think I'm just not good enough, but this post makes me feel less alone. You're so right, everyone dumps on you as the intern because you're at the bottom of it all. =(ReplyDelete
I read your blog and found the effective and highly productive about the Depression and Medical Training ....................ReplyDelete