Our ability to speak freely regardless of role, training, or experience is one element that allows psychiatrists to discuss their fears and limits as clinicians.
Dr Martin is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.
There has been a lot of talk about reforming medical education. Reading through the American Medical Association’s “Accelerating Change in Medical Education” proposals to reform both medical school and graduate medical education, “innovation” certainly remains the buzzword of the day.1 Ironically, this seems to reflect more of an old-fashioned “keeping up with the times” mentality, with a general premise of breaking away from perceived dogma. As to specifically what these “times” are that seem to be passing the rest of us by, and what has become problematically dogmatic in training, I admit I have been unable to locate in any of the proposals other than the broader, “timely” rubric of change for change’s sake.
Granted, the “times” have spun violently out of control over the past 20 years: witness the digitization and corporatization of medicine. The training process itself, for physicians, has remained relatively unchanged. And it is almost certainly the growing disconnect between the end of medical school and the start of residency that is driving the movement to reform training now. The old “medical” world is now the “health care” world, with many different hands in the pot. And whereas physician training remains conservatively geared toward creating “good doctors,” administrative training is often diametrically opposed to this.
Proposals for changing physician training, especially as more corporate entities tinker under the health care hood, rather than suggest administrators broaden their own education more humanistically, focus on aligning physician training more with corporate goals. That is, replacing the time-worn critical-dialectical process with the informatic-algorithm. Less art, more “science”; less wisdom, more analytics.
Standardization or chaos?
In these algorithmic times, then, how is it that we can broaden and make medical education more fulfilling? Currently the clinical training-an experiential mix of bedside lecture, bedside quizzing, and bedside suffering-can be demoralizing, dehumanizing, and humiliating. It can also be inspiring and uplifting. It is a training highly dependent on trust and chance, on both teamwork and individual decision-making. “It could always be worse,” is the telling mantra, and mistakes are not tolerated. In other words, clinical training resists what makes the informatic-algorithm work best: standardization.
And this illustrates the critical difference between medical school and post-graduate training. The greater appeal of medical school today, and especially the pre-medical path, is almost certainly that it offers a rigidly disciplined structure against a tide of otherwise increasingly fragmented and unfocused learning options, especially through adolescence and young adulthood. This phase of training does lend itself well to standardization, at a time in training when it is absolutely necessary.
Residency, on the other hand, is all about the art of mastering chaos. Only worse. Doing so while suddenly crushed with soul-numbing debt, while suddenly scaling impossible learning curves and juggling major teaching responsibilities. It is about mastering the pretense of knowing everything while rapidly absorbing new technological and administrative requirements. All the while studying for licensure exams, applying for fellowships, starting families. All the while negotiating the gauntlet of abuse and bullying from seniors, attendings, nurses, administrators, patients, families.
We used to half joke in residency that this generally “miserable way of being” had evolved as a means of helping one learn about suffering through suffering. Many of my previously jovial colleagues, however, soon found themselves subsisting on the increasingly standard pharmacologic stew of stimulants, “benzoes,” and antidepressants. Burnout reaches its nadir in residency.2 Learned helplessness, PTSD, and the victim mentality are ubiquitous, and one may justly wonder whether “education” is even really the right word.
How then to combine disparate approaches to reform?
Possibilities: thinking outside the algorithm
In these politically fraught times, many have urged activism and advocacy as a means of broadening and providing for more meaningful medical education.3,4 Indeed, such strategies may help somewhat. But just like meditation can actually induce panic in a fair amount of people, so can activism be stifling to many who are searching for that medical holy grail. “Causes” tend to become their own dogma. Critical thought-the cornerstone of all education-often finds itself quashed in the rhetoric and rage of “social justice.” Physicians especially should never close their minds. Certainly, residents should not be forbidden from this path, but if they choose it, they need to be careful of politicizing patients, of taking sides.
Perhaps a more effective strategy would be simply to encourage residents to ask questions more broadly, more conversationally, of their patients, to understand the issues that are meaningful to them (patients), to get to know the neighborhoods in which they work, to learn the history and geography of their regions. When I was a resident, in efforts to develop relationships in the community, we regularly toured the neighborhoods and frequented the shelters, detox facilities, and shantytowns. As a fellow, we often dropped by and volunteered at the local schools and Head Start programs.
By all means, we should educate residents as to their local insurance market, to grasp what their patients will and will not do, what they will and will not pay for, and what they can and cannot afford. Tangential to this are the many “quality improvement projects” initiated by colleagues and administrators, typically through existing electronic health records. Because they are easy (ie, algorithm- and checklist-friendly), they are also good resume and CV filler. These, then, often have very little thoughtfulness or evidence behind them, and frequently contribute more to administrative burden and burnout for the rest of us than any meaningful improvement in quality.
Outside moonlighting is an overlooked opportunity. Often discussed in hushed tones, this needs to come out into the light as this may in fact be the best way to transition from resident to attending. Different hospitals, different systems, different patients, different colleagues. Different ways of doing things. Especially in areas otherwise dominated by hyper-supervised corporate entities where it becomes very easy, and dangerous, to believe in one’s own infallibility, there may be no better way to learn self-reliance and decision-making, to finally becoming a doctor. (And it is an excellent introduction to another unspoken issue: money management.)
The art vs. the science of medicine: Two personal stories
As a resident, I gathered three faculty advisers, two psychiatrists who had written extensively on philosophy and psychiatry, and one philosophy professor who had written extensively on psychiatry. We coordinated monthly meetings with the departments of philosophy, history of science, psychology, and psychiatry. Together we created the Yale Philosophy and Psychiatry Group. It grew every month.
We met over pizza to discuss assigned papers on philosophical issues in psychiatry, medicine, and/or health care in general. We drew guest speakers from all over the world who volunteered their time. Faculty, residents, fellows, medical students, graduate students, undergraduates, and community professionals from all over the region with an interest in any given topic joined us. We published papers, including one well-known and still frequently cited “pluralogue” on the nature of psychiatric diagnoses, written by 25 of us.5
Taking part in this project was easily the most fulfilling and educational part of my time in residency. Not just the academic camaraderie and open-mindedness of the group itself, but that it forced me to read more, forced me to think more. It helped me at least feel more authentic as a doctor, as a thinker, as a human being.
Later, as a fellow at Boston Children’s Hospital, I took active part in organizing educational workshops on training clinicians in the art, and/or lack thereof, of the difficult conversation. Again, these groups were eclectic, the atmosphere designed to allow everyone-regardless of role, training, or experience-to speak freely, to allow everyone to discuss their fears and limits as clinicians. There was extensive role-playing with professional actors, and clinicians universally praised the experience for how it helped them in their practices and daily lives. Many took these seminars over and over. We continue to publish educational articles based on these workshops.
These are the types of educational experiences I believe would be more helpful in creating more authentic physicians, more fulfilled human beings. And perhaps that is the answer: not to avoid dogmatic pitfalls, but to be better able to recognize them for what they are.
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1. American Medical Association. Accelerating Change in Medical Education. https://www.ama-assn.org/education/accelerating-change-medical-education. Accessed January 30, 2019.
2. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA. 2018;320:1114-1130.
3. The Medical Activist Generation. Medtech Boston. August 13, 2014. https://medtechboston.medstro.com/blog/2014/08/13/the-activist-generation. Accessed January 30, 2019.
4. Palma M. Training for Activism, Action and the Future of Medicine. in-Training. May 26, 2016. http://in-training.org/training-activism-action-future-medicine-11054. Accessed January 30, 2019.
5. Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis. Philos Ethics Humanit Med. 2012 May 23;7:9.