As I finished my 24-hour call this morning, I was reminded of a 2009 study revealing a decline in empathy as medical students transition from their mostly-didactic second year to third year, which is essentially an apprenticeship in the hospital with lecture as an afterthought. I began my third year with what most would argue is the most difficult rotation, Surgery, and my experiences over the past 5 weeks have sparked introspection on the things that cause medical students to burn out and wall themselves off during the clinical years.
Numerous factors make the third year of medical school difficult – learning the layout & flow of the hospital, adapting time management skills, the overwhelming volume of knowledge to acquire, and the emotionally-draining experience of moving from 4-5 hours of lecture daily to 14 hours of patient contact in the context of impatient hospital staff are just a few. However, I noticed that the experiences that are the real body shots to our self esteem can be traced back to our mentors.
Lack of mentor continuity: Being exposed to clinicians at different levels of training and with varied style & substance is paramount to good clinical education. However, rotating through teams too quickly can leave us feeling lost and disoriented. Likewise, residents are less inclined to teach when they know they’ll never see us again – they just want to finish the task at hand and steal away for a meal or a nap.
Lack of clinical continuity: It’s hard enough to learn how to manage hospital inpatients, but when doctors start making up their own rules, it gets even harder. Some surgeons prefer different antibiotics to be given before an operation, and that’s fine, but here is an example of when fussiness becomes detrimental: my first resident said he never wanted to hear the term “low-grade fever” – the patient was afebrile if their temperature was below 100.4° F. That same day, our chief resident described a patient as having a low-grade fever. This week, I presented to my new chief resident a patient who had spiked a 100.9° F several times since his operation and I was told that nothing below 101° F should be reported. What will it be next time?
Hostile attitudes: To each other, to the team, and to other teams – this is perhaps the most discouraging practice to witness. Undermining your colleagues is a terrible way to role model, and demeaning your apprentices does not build character, but rather breeds resentment and affects the quality of work your team accomplishes. The lack of professionalism I’ve witnessed at times was more than just thoughtlessness or off-color humor – it was downright inappropriate.
Lack of feedback: I’m not sure how, but some new doctors who were in our shoes just a year or two ago to forget how lost they felt as third & fourth year medical students. We often lack direction, and what we need to improve upon is not always clear to us. Doctors at teaching institutions must be reminded that feedback is the most important responsibility of a mentor, lest the relationship become a one-way street and we regress to the passive nature of the second year.
Lack of forgiveness: Especially true for the technical specialties, like surgery, it’s nearly impossible to get certain things right on your first attempt – I’ve had instruments literally ripped from my hands while trying to suture. Likewise, I can’t know everything about a concentration a specialist has been practicing for years – I was being pimped on breast surgery during a modified radical mastectomy (the first one I’d seen), and when I got a question wrong my resident would roll her eyes and shake her head in disgust. Experiences like that don’t really make me excited to come to work the next day.
Avoiding hands-on training: This is a continuation of my earlier point about residents just wanting to finish and move on – it’s difficult to bounce back and forth between doctors who won’t slow down, teach, and let you do and others who expect you to be proficient and are bewildered when you sheepishly admit this is your first time doing something.
Scapegoating: This is the worst – as a third year medical student, you learn early on not to explain yourself when you’re being scolded (it just results in prolonging the agony). I was recently working the balloon on a Swan-Ganz catheter, an act that requires close cooperation with the person advancing the catheter to avoid damaging vessels. I faithfully inflated & deflated the balloon as the resident navigated through through the heart and pulmonary arteries – just as the attending walked into the room, the resident realized he was retracting the catheter with the balloon still inflated and told me “Don’t ever inflate the balloon without being told!” I just stood there & nodded – to correct him in front of the attending physician wouldn’t have been worth it.
I could post one of the numerous papers on depression & burnout in medical school, but instead I’d encourage you to skim this thread on “3rd Year Depression” from a leading internet forum for medical students. It speaks volumes more than any abstract or numbers I could share with you.
I’m not trying to shift the blame for anyone’s poor performance, but I know I’m a hard worker with the best intentions and I shouldn’t be made to feel lousy so often. My colleagues and I shouldn’t have to shoulder these concerns during this especially demanding period of our education – many of us have already begun to dread our future residencies & entered a kind of “survival mode,” but it doesn’t have to be this way. When we work with thoughtful, professional & understanding physicians, all of these worries dissipate, we perform exponentially better, and with the compassion we swore to display when we first donned our white coats.
Edit (6/30/11): For a different perspective on some of the above issues, check out this post at Skeptical Scalpel’s blog – what do you think?