'Ms. Smith, I have a meeting in ten minutes and I can't find my hidden agenda.'

Discussion in medical school admissions committee:

Colleague: So I asked him “just why do you think you want to be a doctor” and he said, “Oh, you know, I like science, want to help people , like to problem solve.”

Me: I just learned about a new term called “the consent agenda.” In a meeting, if there is stuff everyone agrees on, you put it on the agenda as “consent items.” Then, with no discussion it can pass and you can move on to discussing something germane. I propose we notify all students that love of science, helping people, and problem solving are consent items. Then, we need to find out, how does this person know they REALLY want to be a doctor?

I just learned about this web site called DOC. DOC stands for “Drop Out Club” and it exists to help people transition from clinical medicine into a non-clinical arena such as management or sales. On their web site they say that the “name reflects the sentiment at our original gathering that no clear support systems existed for the paths we were pursuing.”

The site has about 10,000 members, although some may be lurkers like me. The forum at the site is full of folks who feel like they have made a terrible mistake with their lives and are looking for a way out. Many are in residency with statements like “I look around and can’t see myself doing this for the rest of my life” predominating.

Physician career dissatisfaction is a real problem. About 400 physicians commit suicide each year. Suicide is the number 2 cause of death in medical students (following accidents, some of which are also likely suicide). This is thought to be a consequence of underdiagnosed depression, almost certainly made worse by a rapid and monumental debt accumulation. In addition, I will concede that a love of science, a desire to help people, and a joy of problem solving are all good attributes. Unfortunately, they are not sufficient to combat an inchoate  fear that you are 5 years and $300,000 into a terrible, terrible mistake.  And it starts early, also:

A study of all medical students in the United States found that about 49.6% of medical students met the criteria for burn out and 51.3% for depression. Trust me—it’s not all from studying, but from being treated like crap, feeling like we can never make a mistake or ask for help and wondering if anything we do will help to change the status quo or are we just cogs in a wheel trying to crush us.

Approximately 15 years ago, Don Berwick outlined the triple aim for improving healthcare in this country – enhancing patient experience, improving population health, and reducing costs. Tom Bodenheimer recently outlined a fourth aim – improving the work life of health care providers, including clinicians and staff. He identifies the following as some of six things we can do in primary care to keep our colleagues engaged and off the DOC website:

  • Reduce the burden on the physician through team documentation: An encouraging trend I have seen among pre-med students is their being engaged as scribes. This way they get to learn what it is really like to be a physician by being a part of the team and the physician gets to go home without having to do two hours worth of charting after dinner.

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders. Things that are automated should happen automatically with the physician not being a barrier to good preventive care. We need to model this for students

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day. We have gotten rid of the office in our practice. The physician work space is a shared space where interaction can occur. It is really important to level the field.

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice. This holds true for student members of the team as well. They need to understand their role in care delivery as part of the stress of being a student is constantly being thrown into a new environment.

In short, what we as educators need to do is make sure students understand what they are getting themselves into and make sure they have the tools necessary to do the tasks they are assigned. What students need to do is look away from the books and understand that this is not about science or helping people but is about acquiring the skills to enter into a very difficult profession. While interviewing a residency candidate  for our residency it came out that she had been to cosmetology school and had cut hair at Walmart for 2 years. I asked her what the best thing she had learned from that experience was, and she said “When people sit down in that chair and say ‘do whatever you want,’ they don’t mean it.” I suspect she won’t burn out.

 

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