“Are you more or less cynical than when you started residency?”
This was the question my program director asked our senior internal medicine residents at a recent dinner with Dr. Bob Wachter. If you aren’t familiar with Dr. Wachter, he is widely acclaimed as the “father of hospital medicine” and a renowned champion of patient safety and quality. His blog, Wachter’s World, is chock full of insightful commentary on the American health care system, written with levitating optimism. In a time where criticism of doctors and hospitals (coupled with pessimism reflecting the country’s health care system) is trendy, Dr. Wachter’s breath of fresh air is welcoming. It got my program director thinking about cynicism in medicine and inspired this post.
The 30-odd residents, months shy of graduating, got an opportunity to answer whether they viewed themselves as more or less cynical than at the start of their residency training. Many of responses reflected increased cynicism toward “the health care system.” When pressed to explain further, many answers stemmed from the frustration they feel when taking care of patients: difficulty in establishing primary care follow-up for the uninsured, inability to get antibiotics covered by insurance, administrative red tape of setting up home oxygen therapy, and even the cumbersome process of obtaining outside hospital records. It was refreshing, however, to hear residents qualify their cynicism. More often than not, residents did not single out cynicism toward patients as much as they did toward the system. If we are to continue producing generations of passionate and dedicated physicians who don’t burn out, we need to start addressing ways to deal with cynicism.
Short of nationwide reform, hospitals and residency programs can play a part in helping to shape (arguably) the most pliable time in a young physician’s career. While it’s certainly character building to be able to successfully navigate filling out nursing home transfer forms, finding a means to get a patient’s INR checked, making follow-up appointments, and calling insurance companies to plead for antibiotic approval, this type of work should not dominate the daily cycle of residency. There is little doubt that “scut work” helps us better understand the bureaucracy and red tape associated with our health care system, but it also unequivocally takes away from a plethora of formal educational opportunities and it contributes to violations of strict duty-hour regulations.
In speaking to my colleagues around the county, I have found that hospitals and residency programs provide variable support to their housestaff: Some of the best programs offer dedicated resident assistants (typically PAs) and streamlined workflows for discharging patients (multidisciplinary rounds, discharge planners to schedule appointments). Residents who were the least cynical in my unscientific polling were those who had the most resources at their disposal. I wonder if, down the line, the less cynical residents become less cynical fellows and subsequently less cynical attendings. I wonder if these physicians experience less burn out than their colleagues whose training programs do not equip them to navigate the health care maze.
Recognizing that all hospitals and programs are not created equal and that perks such as PAs or discharge coordinators are luxuries that many hospitals aren’t in a position to provide, addressing the larger issue of cynicism in medicine is important. A certain degree of cynicism is healthy but when cynicism borders on indifference or complacency, we’re in trouble. To effectively curtail cynicism directed at the “system,” hospital leadership needs to engage their residents. For many hospitals, residents provide the greatest amount of hands-on patient care. Residents are often the first and last providers that patients encounter during hospitalizations. Every hospital recognizes the importance of quality improvement and creating lean workflows; resident input and feedback should be solicited at every step of the way. Concerted efforts to address issues that plague residents (whether it be better social work support or a lack of computers) should be taken seriously.
Residents need to feel empowered by their programs and hospitals to make changes. Whether those changes are major or minor, a collaborative effort between housestaff and hospitals will inevitably be well received. Unilateral decision making (especially if controversial) can lead to significant resentment and to worsening cynicism. I have no delusions that once residents and fellows finishing their training, challenges in their practice environments (academics, private practice, or industry) certainly can augment cynicism. Nonetheless, if the formative years of one’s training are optimized, scores of physicians might enter their post-training careers with a less cynical mindset.
So now I ask you to reflect on your experiences. Are you more or less cynical than when you started your residency training? If you’re more cynical, why and how much of this was a result of modifiable factors in your training program?
Akhil Narang is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.