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We are the Problem. Are We Willing to be the Solution?

This essay won Resident Category second place in our second annual essay contest “Healthy and Happy doctors provide better care: define barriers and solutions to physician wellness.”

Medical schools have a tradition where students are bequeathed a white coat. These coats announce to all and sundry that we are about to start our shaky foray into the clinical realm. Although I remember feeling no different before I slipped the white coat on than I had after, it meant something to the people who saw me wear it. Now, the white coat is just a garment. It does not bestow any blessings or bring any hexes upon its wearer. But it indicated that I was now (supposedly) experienced and knowledgeable, capable of handling any medical crisis in the hospital. Although it was never meant to symbolize anything else in our lives but our profession, somehow, it tacitly indicated we could also wrangle away all the messiness in our personal lives, that we were capable of smoothing over disputes with loved ones or illnesses or even death itself without faltering in the hospital. And that we could do it all alone.

I was taught to venerate the human body in medical school. Early on, I realized we had come to regard our own bodies as inconveniences and an enemy working against us. I remember clearly the chief of my general surgery rotation when I was a medical student. She had come down with a gastrointestinal virus, looking incredibly wan as she gowned up, but had stoically soldiered through an elective cholecystectomy until she made a strange, muffled exclamation and, without warning, vomited into her mask. Calmly placing her instruments down, gastric contents sliding from the edges of her mask, she walked out of the OR to the sinks where we scrubbed and rinsed her face and neck. She snapped a clean mask on and re-scrubbed. The entire process had taken perhaps four minutes or so. I watched as the attending nodded his approval at her return through the swinging doors. Neither of them referred to what had happened after the case was done. Co-residents who found out about it laughed and clapped her on the back, congratulating her on what I found to be a confusing victory. “My stupid stomach.” She said wryly, shaking her head. Nothing was said to me directly, but I had absorbed the message thoroughly. It told me that illnesses could be overcome with willpower and that perseverance at the cost of my health would legitimize me as a surgeon.

That time, the message had come from the top down. When I started residency, I realized that though we came from different towns and different medical schools, my colleagues had also received the same message and that it nestled quietly in our brains with sharp teeth, pricking us any time we thought we were safe. As luck would have it, one of my colleagues came down with gastroenteritis. They were on a particularly difficult rotation with unsympathetic attendings. Despite their best effort, at one point in the night, this resident had to concede that they were too dehydrated and weak to continue their clinical duties. At the first opportunity, they hid themselves off to the emergency department where a sympathetic nurse administered two liters of IV fluids. Thus self-doctored, the resident walked slowly back to the workroom to continue writing notes.

Physical ailments afflicted these two residents. Unfortunately, I am also well acquainted with the effects the more insidious mental ailments had on my colleagues. A fourth year resident I knew clearly struggled with depression and anxiety. In clinic, his hair was uncombed, he wore wrinkled shirts, and he smelled faintly of mildew. He worked inefficiently and was distant with the patients, his performance only worsening as time went on. The attendings and the residents all watched as he eventually faded from the program and was quietly dismissed one random day. In fact, no one even knew he was gone until we realized we hadn’t seen him in a few weeks. One of his colleagues was relieved, stating that he had never pulled his weight and was a nuisance. I think about how all of us were witnesses to his disease, complicit in its progression. If he had had a non-healing ulcer on his leg, growing ever larger each month, one of us would surely have piped up and dragged him away for wound care. As it was, we all watched him silently and judged him not so silently until he had vanished into the ether. I didn’t blame him for not seeking help. In his shoes, I wouldn’t have either.

As surgeons, we tend to defer to the concrete. We want algorithms and rely on diagnostic criteria and clearly defined actions. “If this patient has a stab wound where bowel is eviscerated, I will operate. I will take him to the operating room for a laparotomy. In doing so, I will save his life.” I would dearly love to present literature-rich, experimentally proven papers to show my colleagues and myself how to be healthier and happier people, but none exist. We have all contributed to a culture of machismo where suffering is good and communication is lax. I do not believe mandated mentorship or required meetings where we sit around discussing our feelings or mandatory work hours will contribute much because it will not change the atmosphere of the hospital and that is the true culprit of our ill health.

What we residents, and even the attendings, need is much more simple, but maddeningly difficult to enforce. We need to create a culture in each hospital where those who are floundering can ask for help and a solid program is available to give that help. As with all change, the culture needs to start from the top. It is of no use to anyone to have a leader say that we can always ask for help but then rolls their eyes or who, by their tone of voice or manner, clearly want us to repress it all. If you are an attending and catch yourself wanting to make a disparaging remark against a sick resident or one who has been overwhelmed by family tragedies, that is the moment to offer sympathy and not stony silence. There are no courses that can teach this. There is only yourself and other attendings who need to hold one another accountable. It is in these seemingly small acts that we residents learn how to be attendings ourselves. Throwaway remarks about the inconveniences of motherhood, depressed residents, or those who take time off for family tragedies are the ones we internalize about our worth. It seeds self-doubt, even in the seemingly confident ones of us. We use these moments to determine who we can trust with our vulnerabilities and who we cannot.

One of the reasons I chose this residency program was for the strength of its residents. It is incredibly relieving to be able to commiserate with the women in my program about frustrations or troubles. I have come to them with struggles and come away with their empathy and their advice, comforted that I am not alone. Having colleagues I can openly communicate with is paramount in making it through this training program. It is something I never fully realized the value of and am making a priority in any future jobs I consider. I know exactly which residents I would come to for help and they are the ones who don’t insult those having a difficult time with mental illness, motherhood, or who are struggling with ABSITE scores or operative skills. They are the ones who listen and laugh or rage with you and insist you seek help when you are over your head. They do not judge and they do not gossip about you with other residents, creating a shameful environment for you. They listen.

Our graduate medical education and hospital administrative folks can help us by making available discreet professional counselors (preferably those with experience in working with physicians), posting contact information for help in the call rooms and work rooms and around the hospital, and being available to facilitate absences or make-up time for those residents who take time off unexpectedly.

The public, and we ourselves, hold our profession to high standards and I believe strongly in those standards. But we are, in the end, human as well and need each other as a source of support and help. To varying degrees, humans are social creatures. There is a primal need to be understood and validated and we can provide that for each other by being open and non-judgmental about those physicians we know who are struggling. We have created a culture where physicians who struggle are isolated and ostracized. We shouldn’t be surprised when that leads to suicide or attrition. This profession calls on us to be empathetic and professional with our patients. Why can’t we be a part of the solution and do the same for one another and ourselves?

About the Author
Dr. Ahn Thu-Le attended the University of Florida for both undergraduate education and then for medical school.  Her undergraduate studies were in biochemistry and entomology.  She was a part of the Junior Honors Medical Program for medical school.  Currently, she is  a general surgery resident at the University of Kentucky and am in my 2nd year in the research lab.  In the future, she hopes to specialize in cardiothoracic surgery.

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