How awful must medical school be?
Future doctors have roughly twice the rate of alcohol problems as surgeons, physicians, and nonmedical workers, according to a new study from the Mayo Clinic, underscoring a problem that many doctors believe has been taking an unacceptable toll for years: something about medical education is putting many students at risk, hurting not only them, but their patients.
About one third of med students reported depending on or abusing alcohol, versus 16 percent of the general public. Students who were single, young, or carrying high debt were particularly susceptible, the authors found, noting that the average trainee graduates from medical school with $180,000 in student loans. Eighty percent of med students reported either alcohol problems, burnout, or signs of depression.
"Our study provides further evidence that distress among medical students warrants serious attention," the team writes, recommending that med schools take a "multifaceted approach" including wellness curricula to help students assess their well-being, and appreciate its impact on the patients they care for. They also call for easier access to mental health services.
But the poor state of medical students' health – mental, emotional, and physical – is not news for many people who have experienced the field's grueling hours and responsibilities. About half of students and residents report fatigue and depression, and doctors are far more likely to commit suicide than the general population.
Mental health and coping 'tips' are popular topics in the medical blogosphere, and many schools are making moves to help, trying to emphasize the availability and importance of seeking help. But to make a more transformative change, some argue, the profession needs to shift its focus from reactive to preventative care, and take a hard look at the nation's century-old medical school model.
In the early 1900s, med school curricula switched from lecture-heavy setups to the four-year clinical model, hoping to tie memorization and book learning to real-world contexts; most schools focus on coursework in the first and second years, then start to immerse students in hospital rounds. Once students enter residency, they'll work up to 80 hours a week, in shifts as long as 16 consecutive hours. That actually represents a huge improvement: before 2003, there was essentially no limit to the number of consecutive hours students might work in a week.
"There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel pressure to project intellectual, emotional and physical prowess beyond what we truly possess," Pranay Sinha, then a first-year resident at Yale-New Haven Hospital, wrote in a 2014 piece about physician suicide.
No one wants to admit that doctors make mistakes when patients' lives are at stake. But inevitably, they do, and some doctors believe more openness about the almost infallible expectations doctors are held to, and the crippling guilt or shame they feel when something does go wrong, would go a long way.
"How are you feeling?" should not be a question doctors only ask patients, Stanford medical resident Ilana Yurkiewicz wrote for Scientific American last year, remembering how much it meant to have a colleague check in with her after a worrying experience with a patient:
One day, I may make an error that falls in the category of more than mundane. I am terrified for that day. But if it comes, I pray I will be in an environment that cares for me so that I may be strong enough to care for the one I hurt, for my other patients – and for myself.
Structuring wellness, self-reflection, and self-awareness into the curriculum, rather than offering such programs as extracurricular 'options,' could be one way to do that.
The American Medical Association's Medical Education Innovation Challenge awarded third place to University of Louisville students' "Happy Healers, Healthy Humans," plan, which called for curricula to strengthen students' communication, empathy, and self-awareness, skills that they believe will benefit patients as well as doctors themselves.
"A big part of our project was making wellness not something you do on the side, but institutionalizing it so it is more of a cultural shift and is fostered within the system," student Melinda Ruberg said in a press release. The team recommended that schools make wellness a priority from orientation on, and offer reflection groups and accountability teams to help students set and discuss their own personal goals, focusing even on things as simple as making time for exercise or rest.
St. Louis University's School of Medicine has already reported promising benefits from curricular shifts in 2009, which emphasized problem-solving coursework, slightly fewer hours, more electives, and specialized learning communities to let students pursue their passions; many students feel that their original motivations get lost in their often bureaucratic, overwhelming experience as young doctors.
"I used to pride myself on my endless empathy, on my ability to engage with people and their problems, and to offer them kind words which came from a place in my heart that truly felt for them," one student wrote for KevinMD.com, a popular blog for health workers. "By the end of third year I find that I am a person who is more concerned about which boxes of which form I can get ticked, rather than allowing myself to engage with a patient facing the worst news of her life."
In the rushed pace of hospital life, paired with endless hours, standard med school training can make patients seem like "the enemy," Dr. David Foster, formerly a co-producer of "House," wrote in a debate about student hours. "That's a terrible sentiment to create in young doctors:
Anything that can be done to change that is for the best. We have done a good job of documenting the medical errors that occur as a result of sleep deprivation. But the human kindness errors are undoubtedly far greater and may actually have long lasting consequences.