Tuesday, June 28, 2011

Why is medical education so demoralizing?

My first year of residency training has ended. As I sit awaiting the start of a new year and new responsibilities that come with being a senior resident, the accomplishments of last year and the excitement of what comes next are overwhelmed by dread - I am not excited and cannot wait for residency to end.

I look around me in the health care sphere and most of what I see is negativity. Exacerbated by the failure of our health care systems, sure, but that is not the brunt of it. As I take leave from medical training and step outside to work on my personal projects in non-health care related fields during vacation, I realized I fear returning to work, to medical training, like a little kid fearing a trip to the dentists.

I look back over my training this past year and realize that everyday is a beating- from my colleagues and never from patients. Every day on rounds, we residents put ourselves up to mean scrutiny - we give presentations on patients we admitted to hospitals, we devise a plan on how to help them feel better - and, of course, we take great pride in what we do and pour a lot of thoughts and heart into these presentations. What we get in return from most attendings and senior residents are often agreements, sometimes additions to the plan, other times harsh criticisms on systematic failures attributed to individual's carelessness (which is seldom true - when things fall through the cracks in hospitals, it is usually due to a systematic flaw bigger than one person), but rarely an acknowledgement that creates a positive work environment. The focus seems to be on what is not perfect, and hardly on what was done well - strides are rarely celebrated in medical education.

There are many instances when residents are "pimped" by attendings - that is, being asked questions to see how much we know. The original intention of pimping (I hope) is to teach, but nowadays I would say that goal is rarely accomplished. Most clinician educators take less than a few seconds to wait for answers while pimping - when do residents have time to think and formulate their responses? A question answered correctly is rarely followed by a pat on the back, only harder questions, some so vague and uneducational most residents don't bother learning answers to. Many times residents are pimped tactlessly in front of patients, whose trusts and confidence are needed for us to do our jobs. I wonder why I feel that the goal of pimping is to embarrass and make us feel stupid.

Last but not least, I feel that my time is not valued. There are many instances when I sit around without any responsibility, waiting just to be let out at 5PM like a 5-year-old because that is when my attendings deem appropriate - I look at people who have autonomy over their own time (like Google employees) and wonder why we are not treated like adults, who can make our own decisions regarding which activities are useful in our training and which are not. There are many occasions when I try to eat lunch in 5 minutes, when I miss a meal completely, when I do not go to the bathroom for 10 hours, when I sleep 4 hours a night, when I work 21 days in a row - and I look at people in other jobs, sometimes nurses, who have a real lunch break, who have real weekends, and I wonder what kind of existence I was living.

On a Southwest plane during my vacation, I read a Southwest magazine featuring its 40th anniversary in business, and a heart-warming theme throughout the whole magazine was how thankful the company was to its employees, how each one of them takes great pride in what Southwest offers and how each one of them was excellent in what they do. Most successful companies have the right idea - the funny thing about humans is if you tell them they are excellent, they become excellent, and compliments and appreciation are rare in medical training.

I can already foresee comments telling me to tough it up and stop whining, but I look at great companies in other industries and employee's morale is never allowed to be quite as low with such daily beatings and abuse. Talk to a resident, and what you will most likely hear are complaints - about long hours, about mean attendings/senior residents, about inefficiency in their workplace. If residency is a long-term job that you can keep until 60, most doctors will not stick with it or want to return to it.

If I could do it all over, I would still pick residency, because my patients made everything worth it, but really, does medical education have to be so demoralizing? Why do we teach people by making them feel small instead of empowered? Does adequate medical training have to come at the price of 10 hours without urination? I challenge us to do better, to build a system where self-esteem is high and residents are well-rested. If Southwest can do it, so can we!


  1. Very true, indeed. I couldn't agree more. And I don't think you're whining at all. In fact, it takes a great deal of courage and toughness to put oneself out there and state truths that simmer in our mind all the time, yet most medical trainees fear talking about, which is understandable, considering that trainees face "beatings" and under-appreciation from virtually all fronts (except from patients, of course).

    Thanks for this thoughtful and profound post. And on a bright side, you're almost done! Pretty soon it's gonna be your turn to beat up residents. Karma! haha.

    Hope all (else) is well, Doc :-)

  2. This is a great post. I've been hanging out with a lot of 3rd, 4th-year, and residents because a lot of my friends are reaching that point now. I've always wondered whether people in the medical profession would benefit from a couple years off working in the corporate world prior to returning to school. This is not a judgment on you, but a lot of my med school friends when they have to work with attendings and interns for the first time and deal with all these relationships, I just think - they are so young, they have not seen real world work other than school. I think that everyone in the medical profession probably could benefit personally from not being in school for so many years before working for the first time. Then again, a great culture at a corporation is tough to build - Southwest, Google, they're the exception, not the rule. Keep these thoughts coming when you can - and hope that you will get through this!

  3. Hey Max and Shang,

    Thank you so much for your kind comments.

    Max: my biggest goal this year is to not beat up anyone and protect my interns, but somehow it's so hard to not pick up from the negative energy around you. Wish me luck and hope you're doing well too!

    Shang: I think a lot of it definitely has to do with the fact that a lot of residents have been in school all their lives before working for the first time with nurses and attendings. I totally agree that a lot of it rides on the fact that we never learn how to manage or run a team efficiently in medical school, even though that is the big brunt of our job every day. However, I also feel that the nature of the job sets you up to be beaten. We present tons of patients every morning, interact with nurses multiple times a day - every one of these encounters is a chance to get sucker punched, and that's because the culture at the corporation that is medicine is negativity. People somehow feel entitled to be so mean and so rude to each other - I kinda wonder if any of these incidents happen in other corporations people will be suing for harassment. I have seen surgeons said fuck you to medical students in front of a patient, I have seen a nurse reducing a senior doctor into tears with her words, and I bet I'm not the only one who have seen incidents like this happen during their medical career. Does this commonly happen in the corporate world?

  4. I couldn't agree more!! Love your article makes me feel a lot better. Ugh rough few months....working so hard and getting criticism in return. And then there are the residents that shirk work and suck and the Attending just smiles, wtf.

  5. Great post. As a former medical student now working in assisted living in Concord NH and the surround areas, I found this to be very interesting. Thanks for sharing your take.