When doctors can't afford to feel | Hacker News Reader

When doctors can't afford to feel

thedailybeast.com

80 pointsjonjlee39 comments

This related and enormously powerful and touching article advises new doctors on how to break the news of a child's death to their parents. Unfathomable responsibility for those distant from performing it: https://www.nytimes.com/2016/09/04/opinion/sunday/how-to-tel...

The real answer to this might be: more doctors. The amount of emotional and psychological trauma any one doctor encounters in a shift in a large city hospital might be 100x what a doctor in a more rural situation might. Undersupply of doctors, higher population density, and cost-cutting have engineered a psychological crisis for the profession.

There are ~29 physicians active in patient care per 10K people in the US [1]. What would it take to make it 290?

[1] https://www.statista.com/topics/1244/physicians/

The problem is that more supply means lower prices so there is a conflict in the medical profession, on the one hand everyone recognizes that tired workers make mistakes but on the other the profession is wary of dilution. In Europe it was really only the Working Time Directive that has had any real impact and the UK succeeded in negotiating an opt-out.

Norway enforces working time regulations and the result is that more doctors have to be employed. About 44 per 10k according to this WHO page: http://www.who.int/gho/health_workforce/physicians_density/e....

However, there is also a different attitude to work here. Generally Norwegians work to live not live to work. In a population of less than five and half million it is reckoned that 100 thousand work enough extra hours a day so that they can take Friday off every week. Even those who don't typically often stop work early on a Friday and make up the time some other day. Salaried employees generally have the ability to vary their hours, can often work at home quite frequently simply because they feel like it, and so on.

I realize that a lot of that is difficult to apply directly to the medical profession but the general idea that overwork is bad for you and the work surely isn't

Edit: a few typos.

I'm not sure why doctors would need to wait for more doctors to be available before collectively putting their foot down and refusing to work these incredibly insane hours.

It still boggles my mind that the medical profession puts up with this this horrible practice that costs the lives and physical and mental health of both doctors and patients.

When medical staff puts "their foot down and refuses to work" patients will suffer. Most feel bound by the Hippocratic Oath[1], in some countries violation of it can be reason for stripping you of your medical license (e.g. in Germany, even though I'm not aware of any case that was handled based on the Oath - you probably violate much more concrete laws if you break the Oath).

https://en.wikipedia.org/wiki/Hippocratic_Oath

> I'm not sure why doctors would need to wait for more doctors to be available before collectively putting their foot down and refusing to work these incredibly insane hours.

Many get paid by the hour.

If they volunteer to do it, that's something else, but I'm not sure how much choice they have, individually.

From the article:

"The therapist’s first question was about my sleep schedule--the likely cause of my distress, but also absolutely beyond my control."

If this guy had control over his hours, he could get more sleep if he wanted to. But he talks as if he's helpless.

I've also spoken to residents who seem to be totally abused and effectively forced to work crazy hours. I've read the same from others. So I'm really skeptical of how voluntary those hours are, though I'd love to be corrected by someone with more direct knowledge.

It's not really a doctor shortage, more like a service shortage: https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...

Generally, there's an ongoing reformation of the system. From the perspective of medical insurance, the current medical system is actually too lax, in that it certifies and retains doctors who get frequent malpractice suits. http://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?... http://www.medscape.com/viewarticle/833141

The solution to that seems like better data on health care (utilization, treatment outcomes, etc.) and accessible analytics (databases for professionals, patients, providers, etc.) and automation of complex/risky procedures/tests (deskilling). But those take time and effort and investments, which have been made but aren't finished/stable yet (somewhere in the middle of Gartner's hype cycle). http://sloanreview.mit.edu/case-study/when-healthcare-gets-a... http://www.webmd.com/health-insurance/using-doctor-ratings-s... https://lukeoakdenrayner.wordpress.com/2017/05/03/the-end-of...

> What would it take to make it 290?

Once people start trusting the system again (which they don't, currently: http://www.hhnmag.com/articles/7802-the-trust-chasm-in-healt...) it might be possible to charge more for services and hence employ more people. But they wouldn't be physicians, the generic trend in society is towards more specialization and more technology. A better question is: What would it take to make it 2.9 physicians per 10K people?

Thank you for posting this. I'm just starting out on a career in medicine myself, and I often wonder how to make it through this with my sanity intact. The idea that the career demands "the subsuming of my inner life" seems cruel and, I hope, not inevitable. Isn't there room to feel our feelings in this job, and not necessarily be ground down by them?

As an intensive care specialist (what would be called an attending in the US) I find it best to control my emotional response to my job. Also, empathy is probably not as wise as compassion in this context, from a career longevity point of view. If you find during your training that you have difficulty setting emotional boundaries and regulating your emotional responses, consider choosing a specialty with fewer unhappy endings (though probably not something with a strong pattern recognition component such as radiology or anatomical pathology, given technological progress in that area - you'd have to expect that we will need less of them as time goes by). There's lots of scope to do less emotionally taxing but still very useful and satisfying work if that fits your aptitudes better.

Some of the best advice I ever read on this subject, which really helped me through residency training was from the little essays at the beginning of the Oxford handbook of clinical medicine [1]. The one I particularly remember was called "On being busy", and taught a generation of UK medical students and residents about "Corrigan's secret door" (the link hopefully shows that page on Google books). My favorite quote from the book was about how to recognise "stress" in yourself: "stress is defined as arguing with more than one nurse in 24 hours".

The book was affectionately known in England as the "cheese and onion book", because the colour of the cover matched what at the time was the traditional colour of packets of cheese and onion flavor crisps in the UK [2]

[1] https://goo.gl/6Pz1Z1

[2] http://www.dailymail.co.uk/sciencetech/article-2293465/A-che...

Thank you for the link to that book.

I sometimes ponder, against my own experience from experiencing the mathematical side of things, how the "folklore" wisdom in the medical community is almost certainly something that the rest of us might benefit from (this probably started when I read The Emperor of All Maladies a couple years back) considering the issues that the mental part of it deals with: ethics, conduct in a power-unequal relationship, consent, the moral imperative to evaluate risk competently (and the recognition that the former can never be done perfectly), telling the truth and intention/effect differences ("you're almost certainly going to die"/"this is a miracle!"), not to mention the elephant-in-the-room question of living with death as a close acquaintance and learning not to become consumed with either anger or despair at what one considers personal failings.

(I suppose the late Oliver Sacks's work is an instance of what I'm talking about.)

Thank you for sharing that; I was able to read "On being busy", and it is lovely.

For those who are unable to grasp the emotional impact of dealing with patients, I would like to mention that Erich Segal's novel 'Doctors' helped me appreciate it better. I found it to be a fascinating read: https://www.goodreads.com/book/show/91201.Doctors

There always be room for feelings, and empathy, but those will manifest only when you're not doing the technical job of medicine, i.e. the part of the job that will require your full attention and the full use of your skills.

This will come naturally with expertise, and is not a state of mind where you actively "force" yourself to stop caring, but rather a kind of single-minded flow[1] where you can only feel completely relaxed and at peace with whatever's happening. This is important because it allows to function at your best and ensures you treat all you patients to the best of your ability, because your immediate motivation is not their wellbeing, but staying in the flow.

What do I mean by those "technical" acts? Anything that requires fine-tuned skill. Everybody thinks of fine-motor procedural skills (surgical techniques, intubation, difficult LP), but purely mental skills are exactly the same. Getting a history from a patient while forming diagnostic hypotheses feels good.

Of course, as soon as you'll be delivering bad news to your patients, you want be functioning like a highly skilled worker but as a fellow human being who can't do much more than commiserate. You wont be in the flow, and you wont feel any less for your patients just because you're the doctor.

[1] https://en.wikipedia.org/wiki/Flow_(psychology)

> When in 2001 resident work-weeks were reduced to 80 hours, for example, it was hoped that we might be less likely to kill ourselves.

> When Your Doctor Is on a 30-Hour Shift

Finishing residency soon, graduation is in two weeks. The program has about a 50% graduation rate. Big fan of the Stoics.

50%??? That seems crazy to me, like something from decades past. If you don't mind me asking, what specialty are you pursuing?

i have to say free ice cream does not sound like a bad idea for these overworked doctors. wisdom is useful but ultimately not something you can eat and it wont give you any pleasure.

I don't understand the problem.

Why can't residents just check in with a therapist each week to ensure that they're mentally healthy?

I went for a few years without a dental checkup because I couldn't get time to do it during the hours the dentist was open. (Granted, I also didn't choose to spend my vacation getting checkups.) In many programs, there is simply so little slack in the system that absence is acceptable only for emergencies.

And, sure, we can talk about how that's bad, unacceptable, etc., but that's the reality that everyone I know lived during residency.

Something like this isn't unheard of either. My wife worked as a sexual assault advocate for some time. Part of the job requirement was regular therapy sessions for her.

You are completely missing the point - they aren't suffering for lack of therapy.

Right-- they are suffering because they entered a training regimen during which, as the author stated, wellness is not an option.

The point is a therapist is trained not only to look for high levels of work-related stress, but also for signs that the patient is at risk of causing serious, long-term damage to their psyche.

It's certainly not fool-proof. But the author seems persuaded that the stress is so high that it requires a new, idiosyncratic moral system for residents. Before doing something that drastic and so obviously prone to confirmation bias, I ask why checking in regularly with a trained, objective third party observer isn't an option.

Sarcasm?

No sarcasm.

I'm talking about employing an independent third party to monitor the stress I'd be putting on myself, and trusting them to tell me if I cross the threshold into lasting damage and/or risking my life.

Is this a requirement for a residency?

Residents barely have time to eat (we called it "low food security"), let alone consider their mental health. I've actually heard it vocalized as a strategy for hospital administration -- keep the residents absurdly overworked and stressed out (and with no way out, since almost all of them have so much debt that leaving the profession is not an option), and they can't muster the coordination to do anything about their terrible working conditions.

Right, I get that. But take this line from the article about the author's free confidential counseling session:

> The therapist’s first question was about my sleep schedule—the likely cause of my distress, but also absolutely beyond my control.

Is the purpose of the confidential counseling session to restore wellness to 100%? Or is it to combat the enormously elevated suicide risk in physicians that the author cites? That it doesn't provide the former tells you nothing about its effectiveness in preventing the latter.

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