Discrimination, Abuse, and Harassment in Medical Training

A recent study (Y-Y Hu et al. NEJM 2019; 381: 1741-52) reported high rates of discrimination, abuse, and harassment based on a cross-sectional survey of general surgical residents (n=7409) in 2018.

Key findings:

  • 31.9% reported gender discrimination and 16.6% reported racial discrimination–with main source being patients/families
  • 30.3% reported verbal or physical abuse and 10.3% reported sexual harassment -with attending surgeons being the most frequent sources
  • Residents who experienced discrimination, abuse or harassment were more likely to have symptoms of burnout (OR 2.94) and suicidal thoughts (OR 3.07).  Overall, weekly burnout symptoms were noted in 38.5% of residents and 4.5% reported suicidal thoughts in previous year

The authors note that there were substantial numbers of programs with very low rates of mistreatment which indicates that improvement in training environment is feasible.

My take: This is a black eye for the entire healthcare field.  It is important to address these pervasive problems and to determine the rate of these issues in other areas of medicine.

Botanical Gardens, Chicago

What Doctors Could Do Together (Organized)

A recent commentary (recommended by one of my sons) by Eric Topol discusses how doctors could be organized to advance the practice of medicine, address the deterioration in doctor-patient relationships, and focus on the needs of patients, whereas current medical organizations are mainly focused on the business interests of medical practice.

An excerpt from Why Doctors Should Organize:

“It’s possible to imagine a new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession. Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients. Its top priority might be restoring the human factor—the essence of medicine—which has slipped away, taking with it the patient-doctor relationship. It might oppose anti-vaxxers; challenge drug pricing and direct-to-consumer advertisements; denounce predatory, unregulated stem-cell clinics; promote awareness of the health hazards of climate change; and call out the false health claims for products advocated by celebrities such as Gwyneth Paltrow and Mehmet Oz. This partial list provides a sense of how many momentous matters have been left unaddressed by the medical profession as a whole…

Because of the unique technological moment at which we live, we may not see an opportunity like this one for generations to come. We have a chance to affect the future of medicine; to advocate for patient interests; to restore the time doctors need to think, to listen, to establish trust, and build bonds, one encounter at a time. For these purposes, and in these times, an organization of all doctors is necessary. Rebuilding our relationships with our patients: that is our lane.

“Pistol Butt” Pine. Tree takes on this shape due to heavy snowfall leaning on tree at early stage. Crater Lake, Oregon.

Briefly Noted: Costs of Physician Burnout

NPR coverage of story: What’s Doctor Burnout Costing America?

An excerpt:

The study authors calculate that for health care organizations, the cost of burnout comes out to $7,600 per physician per year. The study notes that their cost estimate is conservative, only taking into account lost work hours and physician turnover. But other research shows burned out doctors are also more likely to make medical mistakes, have less satisfied patients, and get sued for malpractice, all of which have indirect costs.

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Mental Health of Medical Students

It is well-recognized that there is a high rate of burnout and even suicides among physicians.  The concern regarding mental health extends to medical students.  According to a recent commentary (JF Karp, AS Levine. NEJM 2018; 1196-8), “despite entering medical school with relatively good mental health, medical students become depressed, burned out, and suicidal at alarming rates.”  This is thought to be due to “demanding schedules, cost, and stigma” to obtain mental health services.

The editorial advocates for medical students: “Working closely with the physician-services divisions of large hospital systems may help schools and hospitals leverage resources and provide shared opportunities to improve the care of students, trainees, and faculty and staff physicians.”

Related blog posts on burnout:

Frpm NEJM twitter feed

EMR Learning Curve -Long-term Benefits & Burnout Narrative

  1. Electronic Health Records Associated With Lower Hospital Mortality After Systems Have Time To Mature
  2. Beyond Burnout Moving narrative on the issue of burnout (JAMA link from 33mail -Bryan Vartabedian)

Related blog posts on EMRs:

Related blog posts on burnout:

Physician Burnout -“Hidden Health Care Crisis”

A really good review on the topic of physician burnout: BE Lacy, JL Chan. Clin Gastroenterol Hepatol 2018; 16: 311-17.

This topic has been discussed on this blog and multiple other sites.  This reference covers a lot of ground and provides a lot of useful information.  Also, some esoteric piece of information: “The term burnout first was used in the psychology literature in 1974 by Herbert Freudenberg during his work with drug addicts. He observed that many of his patients would stare blankly at their cigarettes until they burned out.”

Three key components to burnout: emotional exhaustion, depersonalization, and decrease sense of personal accomplishment

Physicians at greatest risk: perfectionists, personal qualities of idealism, and “intense sense of responsibility”

Root causes -work stress (in all its forms)

Prevention of burnout: take care of yourself, exercise, good sleep habits, “learn to say no,” use your vacation time/disconnect

Keys to treating physician burnout:

  • “learn to balance personal and professional goals”
  • “shape your career and identify stressors”
  • “nuture wellness strategies”
  • Try to become engaged in your job
  • Work on resilence

Related blog posts:

Physician Team Cohesiveness

Recently, I attended our medical staff semi-annual meeting.  Two speakers (Dr. Usha Sathian and Dr. Lucky Jain) provided some impressive information about the growth of the hospital system’s outreach with ambulatory care services and about the development of Emory/associated institutions’ academic medicine advances.  The latter includes graduate medical education, extensive grants, and involvement in more than 1000 current clinical studies.  The number of trainees at all levels has grown incredibly.  These trainees are much more likely to stay in Georgia than trainees in many other parts of the country.

This growth corresponds to increases in the hospital’s bed capacity and technical abilities.  A third speaker, Dr. Joseph Rosenfeld, was honored for being both a community physician and attending physician for 40 years!  When he first arrived, there were eight pediatric ICU beds at Egleston Children’s hospital.  Now, there has been about an 8-fold increase.  The number of hospital beds has more than tripled.

Yet, sadly in my view, only a tiny number of physicians attended this meeting, a fraction that attended when the medical staff was much smaller.  Despite the huge increase in staff physicians, there is a dwindling number who attend meetings; this is true for grand rounds as well.  When I first arrived in town about 20 years ago, I looked forward to these meetings to engage and meet my colleagues.  In addition, due to ever larger number of subspecialists, it is much less frequent that when I rotate on hospital service that I will see the well-known neurologist, pulmonologist, endocrinologist, infectious disease expert and so many others.

I came away from the staff meeting with a tangible feeling that despite the incredible success of the system in developing improved capabilities that the feeling of working together as a team of subspecialists and generalists has diminished.  This makes me wonder whether other aspects of modern medicine and the worry over physician burnout are not related to increased isolation of physicians into their specialty silos and to cloistering into our computers and smartphones.

Though I feel grateful to be able to help children in my work, the biggest reason that I chose pediatrics was because of my admiration for the pediatricians I had met and my desire to both emulate their work and to work with them.  I think working closely together is one aspect that makes being a pediatric specialist worthwhile.

My take: Experts have recommended “peer support” to prevent burnout and increase job satisfaction.  My experience, which I suspect is shared widely, indicates that engaging with our peers is becoming less frequent.

Related blog posts: