Becoming and being a physician is “hard duty.” Medical students and residents encounter difficult aspects of life and disease and are often unprepared by their prior personal experiences for what they will learn about the human condition. Physicians-in-training assume responsibility, enact painful decisions, endure long hours, and undergo stresses both mental and physical. They are entrusted with caring for people who suffer greatly, and as a result they often suffer too. In psychiatry in particular, residents engage in honest self-reflection, confront their limitations, change their perspectives, and mature as people. They become more empathic, and some may also become more cynical, but all stretch themselves to do good for others. And typically they do so having to overcome inadequate systems of care for overwhelming numbers of patients in need. This is the task of becoming and being a physician: it is difficult work for the mind and body, and it is also difficult work for the human soul.
In this issue of Academic Psychiatry, we serve up a collection of manuscripts relevant to the rigors and emotional impact of medical training and medical practice. Most distressing by far is the paper by Ahmer et al. (1) on bullying and mistreatment in a psychiatric residency program in Pakistan, finding that the large majority (80%, n=48) of psychiatric residents had experienced at least one bullying behavior in the prior year. Forty-two percent said that they had been ridiculed and humiliated in front of others, and 25% had received verbal and nonverbal threats. Appallingly, 5% had been victims of physical violence. This manuscript is the subject of a separate editorial by Coverdale et al. (2). In another paper in this collection (3), the pervasive and severe stress experienced by cardiology residents in Argentina is documented. In this survey, 72% of the cardiology resident-participants (n=76) indicated high levels of emotional exhaustion, and nearly half endorsed depressive symptoms. In a much larger study of practicing physicians in California (n=763) published here, Bazargan et al. (4) found that 53% endorsed severe to moderate stress, 13% reported using sedatives or tranquilizers, and 7% indicated that they were depressed. Moreover, roughly one-third reported little or no exercise and poor sleep, and one-fifth worked more than 60 hours per week.
These findings are credible, based on prior empirical work on the mistreatment and abuse of physicians-in-training (5–7) and the significant physical and mental health issues experienced by medical students, residents, and practicing physicians (8–11). Each year, for instance, the Association of American Medical Colleges (AAMC) publishes data derived from more than 13,000 first-year residents regarding their medical school experiences (12). Selected data from the most recent survey are presented in Table 1. These findings suggest that bullying and abuse of trainees are salient in the United States, with 17% of residents indicating that they had been personally mistreated; 5% dealing with unwanted sexual advances; 2% stating that they had been hit, slapped, or pushed; and 1% saying that they had been asked to exchange sexual favors for grades or other rewards. Residents indicated that they had been denied opportunities for professional advancement or were given lesser grades due solely to gender, race or ethnicity, and sexual orientation during medical school. Moreover, a significant minority of all of the resident participants believed that the medical school administration was not aware and not responsive to the needs of students. Among the subset of participants (roughly 2,000 residents) who had been mistreated, 48% did not report the incident(s) for fear of reprisal. This is a very worrisome finding. On the other hand, 50% did not report the incident(s) because of the sense that it/they did not seem “important enough,” raising a question about whether mistreatment is too strong a term for difficult interactions in training, or alternatively, whether medical students do not assign as much importance to insisting upon respectful treatment as we might wish them to. Finally, health services for medical students, including mental health services, were not seen as satisfactory for many of the resident-participants.
The data presented in this collection regarding physical and mental health needs of physicians and physicians-in-training were also congruent with prior empirical work, including results of a series of studies performed by my research team and colleagues (13–17). For instance, in a study of 1,027 students at nine medical schools, we found that 90% reported wanting or needing health care (n=924), with 47% endorsing mental health or substance-related concerns (n=483) (13). Students strongly desired personal health care outside of the training context, and they expressed a sense of academic vulnerability if ill (e.g., getting worse grades from supervisors or not being promoted in school), especially for conditions associated most with stigma. In another study, we found that residents feared jeopardy to their training status if it were learned that they were ill—addiction-, HIV-, and mental health-related issues were of greatest concern (18). Residents in this survey indicated that they heard criticisms and negative gossip related to peers who were ill, and a significant minority acknowledged that they avoided and delayed necessary health care in part because they did not believe that they could take the time for personal health care and because they suspected that their confidentiality could not be adequately safeguarded. Findings from the AAMC survey of residents further confirm these concerns: 57% of approximately 13,000 respondents endorsed that “the demands of a physician’s work interfere too much with family relations” and 54% agreed that these demands “interfere too much with other interests and pursuits” of importance to living a full life (12).
The papers by Haak and Kaye (19) and Mangurian et al. (20) offer perspectives on other critically important and deeply affecting personal aspects of postgraduate education: the psychological tasks and educational issues involved in obtaining one’s own psychotherapy during residency and the complex issues that arise in living through the experience of having a patient commit suicide during residency. Haak and Kaye (19) documented that fewer psychiatric residents than in the past are engaged in personal psychotherapy. Those who were in therapy reported its value in their professional development as well as personal well-being; the principle barriers to engaging in therapy were cost and the demands of training that made it difficult to find time for treatment. Mangurian et al. (20) discussed the isolation, self-blame, worry, and emotional distress associated with the trauma of a patient suicide during residency training. They described their efforts to create a positive “crisis support” team to aid trainees who undergo this most difficult experience. These steps in attending to the psychological needs of physicians-in-training and to supporting positive self-care behaviors are important in preserving the well-being of physicians but also in enhancing the caregiving skills of physicians (18, 21, 22).
Distress associated with caring for patients is a thorny topic, and it is one that has received relatively little attention. Academic Psychiatry has in the past published papers related to this area, for example, in relation to physical assault of residents by aggressive or combative patients (7, 23). The AAMC resident survey data (12) again point to the salience of this issue for medical students, as patients were identified as the source of mistreatment by 30% of individuals who experienced this in medical school. Patients were identified as the fourth most prominent source of mistreatment behind residents/interns (67%), clinical faculty in hospital settings (66%), and nurses (43%).
The apparently widespread phenomenon of mistreatment in medical training may remind us of how patterns of abuse may be propagated over generations in families. We are left to speculate as to whether these same patterns may be similarly sustained over time in training settings and health care systems that, intentionally or not, support disrespectful and unprofessional conduct. The experience of being a physician-in-training is traumatic, as Klamen (personal communication, 2001) and others (24) have suggested. Direct encounters with disease and the suffering of patients combined with long hours and exhaustion of clinical training—let alone unkindness experienced in dealings with colleagues or patients—are harsh. Thus, it is argued, the educational process itself makes every physician prone to cynicism and vulnerable to becoming an “aggressor.” To be explicit, at least in theory, students who have experienced mistreatment are at heightened risk for becoming enactors or enablers of the same behaviors as they become more empowered in the future (Montalvo, personal communication, 1993). It is for this reason that concerted efforts to improve the environment of training, to emphasize the importance of personal health and well-being, and to engage in appropriate self-care behavior is critical for medical students, residents, and practicing physicians.
The price one pays for pursuing a profession or calling is an intimate knowledge of its ugly side.
Taken together, these papers document dark aspects of the culture of medicine. That any trainee would ever feel physically threatened; would feel pressured to trade sex for grades; would feel that his or her gender, race, or sexual orientation solely caused him or her to receive fewer professional opportunities or worse grades; or would be retaliated against for raising concerns about professionalism issues in the training environment is cause for great concern. It is absolutely clear that we do not yet foster the development of physicians as whole, healthy, and complete people, nor do we yet insist that their training and practice environments exemplify the standards of professionalism to which we aspire.
And yet the authors of these papers—just by asking the questions they do about mistreatment, health care needs, self-care activities, and the need for appropriate support in times of tragedy—assign priority and value to these considerations. In assembling this scholarship, our colleagues provide a sense of perspective on the importance of continuing to work toward a brighter and more brilliant culture of medicine in which the well-being of our colleagues is held dear, as is our commitment to the well-being of our patients.
Academic physicians may thus have another challenging task among all the other responsibilities we assume. As teachers, doctors, researchers, advocates, and leaders, we must keep our commitment to examine thoroughly and honestly the ways in which the culture of medicine requires deep revision. Then we must act deliberately and courageously, starting with improving the experiences of our early career learners. Changing the ways of medical education will not be easy, but we are quite accustomed to hard duty—in fact, I doubt we know of any other kind.