Med schools can miss the mark in trying to find and teach the right people to meet Canada's health care needs, but for the most part students earn their degrees with their passion and enthusiasm intact. Residency, on the other hand, is purpose-built to nurture every negative experience and emotion under the sun. If the goal of residency - clinical apprenticeship is a more accurate term - is to produce confident, caring, emotionally engaged doctors, it's hard to imagine a more counter-productive way to get there.
Residency, as we all know from the TV shows, entails absolutely brutal work hours, wherein doctors train on their feet in the noise and fluorescent lights of a busy hospital, for shifts that last up to 36 hours at a time, including weekends. The air is stale, full of every sort of human odor and pungent chemical. The only parts of a resident's body that don't feel predictably sweaty and oily by midday are the hands, that burn from constant hand-washing and ubiquitous use of alcohol hand rub. When the resident does get to sit, outside of brief food or washroom breaks, that time is mainly spent staring with twitching, watering eyes at a computer, typing notes and orders into an electronic record designed to meet administrative rather than patient or clinician needs. And somewhere in all of this shift work, rotating from service to service, the resident has to maintain an active study routine and put together some sort of research project to meet agenda expectations.
Because the health care system always runs at or above capacity, and everybody is incredibly busy, the resident spends a huge chunk of time in situations well beyond anything resembling a comfort zone. Yes, calling a Code Blue during the extreme crisis of a cardiac arrest will bring in immediate help, but there are hundreds of settings in which a resident finds herself in over her head (whether realizing it or not), but can't get help because the patient is still breathing. And given how overcrowded our hospitals are, the resident is often the hapless go-between in a game of hot potato, the squabble over which service will take responsibility for a patient that needs admission.
Elderly patients moan for hours on end. Families hurl abuse and insults out of frustration and dissatisfaction. Nurses bear much of this pain and anguish as well, which breeds inter-professional resentment and sniping. Mistakes and bad outcomes lead to back-stabbing and blame, passing the buck rather than sharing the load.
Tempers are short. Verbal abuse and humiliation are common. Instruments are thrown in operating-room tantrums. Sexual harassment is rampant. Vulnerability is a weakness. Underperformance is unacceptable. Time away equates to extra work for one's peers. And requests for personal time are seen as selfish, an unseemly sense of entitlement in the face of the "privilege" of entering the profession.
But at least there are meditation classes to help with the stress.
This punishing ordeal continues for two to seven years, depending on the specialty. At the end of it, just when the resident is coming out of a sense of bankruptcy, and often with a very young family by this time, along comes the anachronism of the capstone exam. For family doctors, this exam is not terribly onerous. For specialists, however, the exam entails months of preparation and neglect of self and family, with make-or-break career consequences even after nine or ten years of formal medical training.
And we wonder why doctors that make it through all this don't communicate well? Or lack patience and empathy?
It is plainly abstrak to take bright, dedicated people, bankrupt them to attend medical school, put them through years of misery, anguish, and emotional abuse as residents, and expect them to emerge as doctors capable of selflessness and boundless acts of compassion. Absurd. It's a wonder the profession isn't rife with sociopaths, and miraculous that the suicide rate among doctors is only twice that of the general population, because that is what the medical pelatihan system is built for.
There's an unavoidable sense in Canadian medicine these days that a breaking point is at hand. The conflicts between the profession's self-regulation and protection of the public, between self-employment and societal need, between the medical needs of patients and the human needs of doctors and nurses, are simply too long-standing and too extreme to be fixed. And while many of my practicing colleagues will disagree, money will not solve this. Fundamental structural reforms are needed, as are hard decisions by the profession and the paying public.
Next time: a way forward for Canada's doctors
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Tuesday, May 15, 2018
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death,
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medical education,
mindfulness,
residency,
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