A Call To Reform Medicine’s Killer Work Culture

My apartment has a balcony directly overlooking the hospital where I am about to start my final phase of physician training as a medical resident. In March, as I was preparing to graduate from medical school, a resident at one of my institution’s affiliate hospitals jumped to her death from her apartment building. From the brief time I knew her, I remember that she lived close to work; perhaps she had a view similar to mine. As I take in my new campus, anticipating the daunting responsibilities soon to be entrusted to me as a doctor, I wonder whether she was looking at or thinking about her hospital during her final moments.

This resident was the third to commit suicide in New York City in the previous 19 months. Even before the first occurred in August 2014, doctors and the lay public openly discussed how the profound professional disillusionment experienced by many physicians in training contributed to their markedly higher than average rates of depression and suicide. But even as this nationwide conversation took shape, the medical community as a whole continued to neglect the root causes of the doctor-in-training-depression epidemic.

...the medical community as a whole continued to neglect the root causes of the doctor depression epidemic.

When I learned that a colleague whom I had both admired and identified with had killed herself, I was horrified. But what most disturbed me were the expressions of resignation, rather than shock, of the residents around me. My colleagues agreed that depression, sometimes leading to suicide, is an inevitable consequence of the residency work environment that will persist unless a significant cultural shift occurs. Eager as I was to begin the next phase of my training, I began to fear that I had chosen a career that could threaten my wellness.

I tried to take comfort in knowing that residency programs in New York and across the country have already undergone major structural improvements to prevent burnout and stress. Over the past 15 years, the Accreditation Council for Graduate Medical Education dramatically reduced duty hours and required residency program directors to promote trainees’ well-being.

New York residents are doubly protected by state law prohibiting residents from working more than 80 hours per week or more than 24 consecutive hours. However, a recent study found that — as these suicides demonstrate so clearly — resident depression continued despite these changes. Why, I wondered, would earnest efforts to improve working conditions fail to translate to better outcomes in resident well-being?

The answer is that it is facile to attribute depression among residents to fatigue and modifiable stress alone. Rather, residents I spoke with described a sense of helplessness that develops when one is constantly criticized and rarely appreciated. They reported that attending physicians, consultants and nurses often spoke to them disrespectfully. First-year trainees were made to feel incompetent by supervisors who neglected to teach them practical patient management skills, an entirely different animal from the pathophysiology taught in medical school. A systemic illness, of which demanding hours and a busy workflow are mere symptoms, plagues the culture of medicine. As with depression itself, treating the symptoms without addressing the underlying cause of this problem is unlikely to result in a favorable long-term prognosis.

...efforts to improve resident wellness should emphasize respectful treatment and building self-confidence throughout the training years.

Instead, efforts to improve resident wellness should emphasize respectful treatment and building self-confidence throughout the training years. Residents should be given opportunities to openly discuss insecurities about their clinical skills rather than being instructed to “fake it until you make it.” They should be encouraged to ask questions, and they should not be berated for not knowing an answer. The traditional sink or swim method should be replaced by instruction tailored to address individual residents’ areas of weakness and help them overcome feelings of inadequacy. Learning should be a guaranteed right, and trainees should always feel worthy of their superiors’ time. Unlike duty hour restrictions, which serve chiefly to reduce medical error by improving clinician alertness, these resident-centered reforms could have a real impact on depression and suicide rates.

Those of us who believe that resident wellness ought to be respected as an end in itself often meet with resistance from fellow members of the medical community. One morning, I had just gotten off a phone call reflecting on the March suicide when I was approached by a man wearing scrubs and a white coat — presumably an attending physician — who apparently had been listening in on my conversation. “You know, when I was a resident, this whole wellness concept didn't really even exist,” he said, without introducing himself. “So best of luck to you.”

As he walked away before I could formulate a response, I was struck by how quickly and completely he dismissed a philosophy with no agenda other than to prevent future tragedies. Thoughtful interventions to ensure that residents maintain healthy self-esteem are desperately needed. We can only hope that such interventions will garner the support they need.