A father’s call to action in a recent article made me feel several feelings.
The dad is a doctor and he was rushed into the intensive care unit to see his daughter, a surgical resident who had swallowed a bottleful of antidepressant pills and was now delirious with frightening writhing and contortions.
He and his wife were spurred on to parental combat by what they saw, as in past episodes that were less dire. Then, they reflected on what they and others had done and failed to do.
The daughter made this attempt at self-annihilation after previous bouts with depression and suicidality. What pushed her over the edge was her training program’s brutal hours and workload and unsupportive culture.
Quotes from the dad
The following passages stood out:
“A general surgery residency, however, quickly unmoored her, making her vulnerable again to the undertow of depression. Work hours, often exceeding 90 per week, left no time to establish care in a new state. A 5:00 a.m.-to-7:30 p.m. schedule precluded online appointments. Prescriptions lapsed. The stressors of caring for the gravely ill during a pandemic turned an already-impossible job into one saturated in toxicity and hopelessness.”
“Meanwhile, her residency program’s culture, like many, promoted dishonesty in duty-hour logs and unquestioning acquiescence to leaders and loyalty to coresidents. When her program lost four trainees, her workload increased.”
“Once again, establishing care, medication, outpatient therapy, and the simple self-care of eating, sleeping, and stress management alleviated her symptoms. Feeling obligated to her coresidents, she resumed full-time duties after 6 weeks. Her program director assured her she could graduate on time if she limited her vacations during the next 3 years. Implicit in the bargain: no relapse. But without time for mental health care, her symptoms recurred.”
“On day 5, her program director called me, asking when she planned to return: she hadn’t answered his calls or emails, and he had a schedule to finalize. His concern ended there.”
“12,000 U.S. physicians, at a rate of one per day — twice the suicide rate of the general population.”
“Though my daughter clearly had risk factors, the culture of the profession thwarted attempts to mitigate them. Practitioners in other fields pride themselves on protecting one another. Yet we purported healers tolerate stacks of body bags filled with our dead colleagues, after people like me have failed to understand the depth of their suffering.”
The saddest detail is the lack of support from fellow trainees in the program
The saddest detail for me was how basically no one supported the woman. One resident stopped by. One sent a text.
“On day 2, a close friend from residency stopped by to check on her. “I’ll let the residency program director know,” she said. I saw no other physician friends during her stay.”
“She was sent a link to a policy manual. No meeting occurred. But the most painful and telling response came from her coresidents, administrators, and educators: nothing. Beyond one text from one coresident, radio silence. The community abandoned her.”
To put a finer point on it: suppose you are going through a difficult program with a group of people who have known you for months or years, and they find out you tried to kill yourself and were hospitalized, and none of them reached out? How would you feel? Where is the solidarity?
Brutal work hours and a link to Cialdini’s findings on hazing and initiation
Doctors in the US face a brutal training period that lasts over a decade. The training has elements of hazing and initiation. It promotes bullying and hypercompetition. And once they go through it, they tend to inflict hazing on the next generation of doctors, consistent with the psychology of commitment described by Robert Cialdini. The following example is from college fraternities but holds true for US medical training:
“We see escalating commitment most clearly in the elaborate hazing rituals practiced by American college fraternities and sororities. Pledges are subjected to harrowing ordeals where they are beaten, exposed to extreme weather conditions, forced to drink to excess, deprived of food and water, and other elaborate forms of painful initiation. Hazing like this has resulted in severe injuries, psychological trauma, and even death for many college students.
Why do these organizations continue subjecting their members to what can only be described as ritualized torture? It’s not that frat boys are uniquely sociopathic or deviant (as their detractors would like to believe).
The psychology of hazing is really all about group cohesion: the pledges will value their membership in the fraternity more if they’ve gone through excruciating lengths to earn it. Researchers believe that the roots of this lie in cognitive dissonance—the mental burden of carrying two contradictory beliefs at once. The worse the hazing is, the more your mind needs to convince you that joining the group will be a positive, fulfilling experience. Thus, hazing binds new recruits closer to the group through escalating commitments: you invest more into the group, because it’s impossible to stomach the idea that you went through all this hazing for something you don’t actually want. The escalation of commitment bias works in favor of group loyalty.
The fraternities strongly resist any attempts to substitute their hazing rituals for some other, more socially acceptable activity, like community service work. Like the Chinese Communists, the fraternities don’t want to give their pledges a mental “out.” They don’t want new members to be able to tell themselves that they’re going through the ordeal for any reason other than their loyalty and commitment to the group. That’s what the psychology of hazing is built on. Fraternities want the pledges to own the commitment intrinsically.”
Doctors are leaving the field. Difficult process of winnowing. AMA blocking solutions.
“In my daughter, medicine lost a practitioner of unquestionable skill, commitment, and compassion.”
The daughter was extremely smart and hard-working, and she treated patients and nurses well. She thrived with basic self-care, such as keeping therapy appointments, medication, eating and sleeping properly, and being with family. Her elemental powers of resistance were intact, but were weakened by the environment she was in. She would have made a great doctor, but now the field will lack her contributions forever.
Doctors are leaving the field in greater numbers. The US medical system is ranked last in quality among industrialized countries. Medical educators see their job as winnowing candidates out through difficult trials. After all, for each person who fails, there are hundreds willing to make greater sacrifices to take their place.
Yet others refuse to enter the field, viewing it as a way to sacrifice your 20s to hard work, only to receive a lifetime of hard work in exchange.
And to make matters worse, the American Medical Association (which does not represent all US physicians) lobbies to keep the number of new trainees low and to restrict the scope of practice of midlevel practitioners.
Side note: infant genital cutting and “unquestioning acquiescence to leaders”
I can’t help but include my opinion on infant circumcision.
I am totally opposed to non-therapeutic genital cutting of non-consenting persons, which includes infants. The practice is a violation of the rights to bodily autonomy and bodily integrity.
The perspective article includes the phrase, “unquestioning acquiescence to leaders.”
This unquestioning acquiescence to authority is one of many reasons why genital cutting of male infants is rampant in the US: a culture of medicine where residents venerate their “attendings” (as their mentors are called) and repeat what they were trained to do unquestioningly over their career, in a way that contradicts evidence, ethics, and common sense.
The above note on brutal initiation rituals holds true with infant genital cutting. Parents also think that since the dad went through this blood ritual, the son must be subjected to it also, otherwise the cognitive dissonance remains unresolved: “Why would someone have inflicted harm on me by cutting my genitals needlessly? That makes no sense. If I don’t cut my son, then I have to grapple with the idea that something pointless was done that harmed me. So, we must continue the tradition by cutting our son.”
Endless wisdom from The Magic Mountain
The Magic Mountain by Thomas Mann treats very humanely of disease, suffering and the sometimes-questionable role of the doctor. The following passage is about a character who abided by a code, to both his honor and detriment, and later felt “shame and self-reproach” for faltering to a powerful affliction:
“What or whom was he dodging when he hid his once so open gaze? How strange that a creature feels ashamed before life and slinks into its den to perish, convinced that it cannot hope to encounter any respect or reverence for its sufferings and death throes – and rightly so, for joyous birds on the wing show no honor to a sick comrade in their flock, but instead peck him angrily, disdainfully with their beaks. That is base nature’s way – but a very human, loving mercy swelled up in Hans Castorp’s breast when he saw that dark, instinctive shame in poor Joachim’s eyes.”
Last word: “It’s time we started looking after our own”
American doctors go through rigorous training to pursue a career healing the sick. I don’t mean to disparage them as indifferent bullies. But the culture, especially during training and residency, needs to change.
The article ends with a call for doctors to do as members of other fields do and look after each other.
About the photo
Two women with the same outfit on the Seattle waterfront in Fall 2022.
pseudoisaac 