Wednesday, December 13, 2017

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4th night and taking every 4th admission, and the two interns on each service thus taking every 8th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4th night call was a big change from every other or 3rd night, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.

And as people.


Allison Edwards, MD said...

...perhaps residents are unhappy because instead of having a "commitment to something greater than yourself and your self-interest," we are finding that we're really just working for faceless corporate buraucracies that abuse everyone involved, including patients, residents, and attendings? Just a thought :)

Anonymous said...

Thank you for your thoughtful post, Dr. Freeman. I completed my residency in internal medicine at Bellevue Hospital in New York in 2008. I, too, was drawn to service in a famed urban public hospital, and I agree that having a sense of greater purpose is an important factor for job satisfaction. I have another suggestion, however, about the "unhappiness" of current residents. Could it be, perhaps, that the job has changed? I remember a senior attending waxing poetic about a time that she spent all night at the bedside of a critically ill patient, monitoring fluid status and urine output and was able to see him safely through the night. I remember feeling jealous that she had that much time to spend with one patient. I remember ushering my iPatients safely through the night through screen-blurred eyes. I remember feeling pressure to shuffle patients through the revolving door of the hospital as quickly as possible due to administrative pressure on "length of stay." I don't think the amount of work is the problem; it is what one is doing while at work that is key.

Evan Gooberman said...

This is probably the first time I disagreed with most of your points, Dr. Freeman. Usually your blog posts are very inspiring and build enthusiasm for good causes to improve healthcare and health policy. I feel that this post, however, misdirects its energy. It reminds me of James Reason's swiss cheese model because all of the holes need to line up for an error or near miss to occur. When an error does occur, as a society, we tend to place the blame on the sharp end of the spectrum (the provider). I draw the connection because I fear that this post and other pieces I've read blame residents for the problems that are really caused by systems issues. Most residents care about their patients and want to be exceptional physicians for said patients. And, they want to be happy while doing it. The system that residents have to operate in (pun intended) is difficult to navigate, mostly because of issues that you have so passionately discussed. It is tough for me to compare the system now and the system when you went through residency because I did not see the system firsthand, but there are some differences that can have a big impact on the lives of residents. Some examples include the older average age of residents, the increased cost and thus debt burden, the explosion of information, the increased chronic conditions of patients, and the list goes on. The reason I felt compelled to respond is not to prove any points wrong or to get into an argument but to suggest focusing our energies as a profession on the real issues at hand. We should work together to improve the system in which we work, for ourselves and our patients. I think we will find that residents' happiness, or lack thereof, will no longer be a huge concern.

Josh Freeman said...

Thank you, Evan Gooberman. I never expected anyone to agree with everything I wrote, so I am grateful that you continue to read. I think my main points (and I hope they came through) were 1) that whatever reason residents might be unhappier now than in the past is not due to greater workload, and
2) that having a sense that one is actually making a contribution during residency, not just preparing for the future, helped me and others.
I do not know, actually, if residents today compared to in the past are happier or unhappier, more or less likely to have that sense of making a contribution, or whether most residents who were not at Cook County when I was were unhappier. I think that the points you make (about age, debt, sicker patients in the hospital, etc) are good ones. For me, of course, being a resident was (in Family Medicine) also largely about caring for my continuity panel, so not solely hospital. In addition, the greater number of rules and regulations (including EMR) and emphasis on making money for the hospital are big negatives today.
I hope that the issues that exist can be worked on by all -- residents, program directors, RCs, hospitals, etc. -- in good faith with emphasis on excellent patient care.
It will be more up to you than to me. Good luck!

David Warner said...

Wow, great post.

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