October 14, 2005
Surviving in the Culture of Mean
The first month of my internship is an enduring memory. Within 30 minutes of hitting the front door of the county hospital I was attacked by a rabid attending. She turned out to be perhaps the truly meanest (or perhaps unhappiest) person I have ever met in medicine. For the next thirty days I was constantly screamed at, verbally abused, demeaned and never allowed to leave the intensive care unit--even to eat--on a 24-hour shift. I lost 25 lbs. I almost told her where to put the job. But I stuck it out. This experience didn’t make me a better physician. And it didn’t make a better person. Welcome to the culture of mean.
I was reminded of this experience by The Informed Patient column in The Wall Street Journal from September 28. There Laura Landro writes about "Teaching Doctors to be Nice."
Physician meanness and emotional dysfunctionality (abused child syndrome) is one of those common experiences about medicine that is little discussed, but most certainly impacts the patient experience and possibly the outcome of receiving healthcare. And perhaps impacts such things as the high suicide rates in physicians.
The article describes the problem thusly:
“Medical educators call it the 'hidden curriculum' -- the negative messages medical students get in front-line, residency training that seem to contradict everything they had been taught about ethical behavior, compassionate care and professionalism. Researchers say the most powerful influence on future physicians is the behavior they observe on a day-to-day basis in the medical-school environment. And what they often learn is how to be cold, intimidating, authoritarian, narrow-minded and disrespectful of subordinates and patients.”
Although accurate, this statement barely describes the extreme nature of the environment of training in this regard.
“Medical schools have long acknowledged the problem. In the past few years, there has been a movement to add courses on professionalism, empathy and communication skills. But there is mounting evidence that the new curriculum hasn't been effective. Paul Haidet, a professor at Baylor College of Medicine and an internist at the Houston VA Medical Center, has helped measure such efforts at 10 medical schools and says his surveys show the coursework is routinely undermined by what students see watching doctors in action.”
Medical schools are attempting to address this problem. However, they are doing it in the usual mechanistic, bureaucratic, totally intellectualized way that will lead to checking it off their “to do” list, but may not accomplish the task. And who’s teaching? Everyone there is a product of the culture of mean.
“New standards from the Accreditation Council for Graduate Medical Education are spurring medical schools to move more aggressively than ever to change their culture. Starting next year, the council will require programs to demonstrate how effective they are in teaching students six basic 'competencies,' which include compassionate care, ethical behavior and professionalism along with mastery of medical knowledge and technical skills.”
I haven’t seen the material and I do hope it has favorable impact, but this sounds like an exercise in intellectualization. Where is the emotional human-to-human connectivity? Where is the teaching to use the whole intellect, both the rational and the emotional?
The culture of medicine in addition to being mean extracts a great personal cost in social isolation and disrupted social networks. Writing in the June 16, 2005 issue of the New England Journal of Medicine in an article entitled "Taking Their Own Lives—The High Rate of Physician Suicide," Eva Schernhammer, MD, DrPH explores the possible explanations for why physicians even starting in medical school have higher rates of suicide than other sectors of the population.
Perhaps the system selects for the antecedents of suicide since the trend starts in medical school. The incidence of depression, alcohol and drug abuse are all high in physicians. The trends are more pronounced in women physicians though are also high in men.
“Another way to view the problem is that the professional burden carried by doctors leads to social isolation and an increased probability of undergoing phases of disturbances in their social networks. It has also been noted that physicians tend to neglect their own need for psychiatric, emotional, or medical help and are more critical than most people of both others and themselves. They are more likely to blame themselves for their own illnesses. And they are apparently more susceptible to depression caused by adverse life events, such as the death of a relative, divorce, or the loss of a job.”
I don’t know the relationship between the culture of mean and the physician suicide rate, but it does make one wonder.
Despite our training, many physicians end up nice and respectful and civil and have relatively normal human emotion. But one doesn’t have to walk too many hospital hallways or attend too many staff meetings to see ample examples of the culture of mean and egocentrism in action.
Though physicians certainly have diverse personality traits and aptitudes, I have often observed that the system selects for three common traits in physicians: high intelligence, high industry, and competitiveness to the point of self destruction. Perhaps our training simply leverages these traits to create the culture of mean.
As we ponder the Future of Health and the impact of consumers on physician interaction, I suspect the culture of mean will come under great challenge. Academic medical centers have an obligation to address and remediate the culture of mean. To do so will require them to face their own exorcism first.
