I have the pleasure of having medical students and residents in clinic with me a lot of the time. Their purpose while in clinic is to learn. Learning objectives vary depending on the trainee. For example, a third-year medical student’s goal while at the cancer centre might be to learn how to give bad news or have difficult end of life conversations with a patient, whereas a medical oncology resident might be more focused on learning clinical trial data that drives our decision-making processes. Though not specifically on the learning agenda (although it should be made a priority), I try to infuse some discussions about wellness into many of these encounters. I had a conversation in clinic with a trainee that inspired this post. Our exchange left me sad – for them, for my past self, for current and future colleagues.
We had stumbled upon the topic of retirement. I am nowhere close to being able to retire but I commented that when the time comes, there will be a firm stop date. Some colleagues stick around to finish up projects or to help with extra clinics. That won’t be me. My clinic nurse and pharmacist agreed that was their plan too. There won’t be any half-in and half-out for us.
The trainee chimed in and said we shouldn’t retire anytime soon as we are too good of a team and very good at teaching. This prompted some more words about how lovely of a learning environment we provide at our cancer centre and how different it is from some of the rest of their training. I asked them to say more.
They went on to explain how beaten down they felt and how little support there is for medical students and residents. They commented some supervisors are rude, cruel even. Though not said in so many words, collegiality seemed non-existent and demands unattainable.
As I listened, my heart sank. They were describing my experience over twenty years ago, most notably during my Internal Medicine training at the University of Alberta Hospital. Had nothing changed? Why are we still treating our students and residents so badly?!
The single most powerful memory I have of my medical training is from almost twenty years ago. It is not a good memory. It has nothing AND everything to do with actual medicine. Flashes of anger, aimed toward the two staff doctors who were involved, still flicker inside of me about this.
I was a third-year senior internal medical resident. I had already completed four years of medical school and two years of internal medicine residency. One more year and I’d finally find myself in the training program I had worked so hard to get to – Medical Oncology – hopefully where I’d feel a little more human. The last two years had been rather difficult, flush with what felt like continuously being on call, having little to no sleep, feeling never good enough for always doing what was literally my best for the patients in front of me each day. I couldn’t have given any more.
My bad memory is from the Monday of the first long weekend in July. I had been awake the entire day and night before being asked to see all the general internal medicine cases that required a consult or admission in the emergency department along with all the emergencies that were happening on the wards. I was the lead resident in the hospital and had a team of two junior residents and a medical student. There was a staff physician we ran cases by who was ultimately responsible for the patients we treated. We worked together to review cases, make recommendations, admit patients that needed inpatient support, and put out fires as they arose.
A few hours earlier, just after midnight, I was asked to see a patient in the emergency room who had just days before been discharged from the hematology service for a blood disorder. The patient was back, feeling unwell again. Internal medicine (my team) was asked to see and re-admit the patient. However, there was a general rule in this hospital that should a patient need quick re-admission, the care team should remain the same as the previous admission (in this case, hematology not internal medicine). This saved work and time and was arguably the better solution for the patient, since the patient was already well known to that team.
With this rule in mind, I took a history and did a physical exam, agreed with the emergency physician that the patient required admission to the hospital, and called the hematology resident to take over care responsibilities. The hematology resident agreed to see the patient, thus removing my involvement in the case. I went on to tackle other waiting patients.
That did not go over well with the hematology staff doctor. She was irate when she came in the next morning. While my team was making our rounds in the emergency room, she marched over and yelled at me. I mean red-in-face YELLED. She yelled at me in the middle of the emergency room, in front of my team, other health professionals, and in front of patients. I was incompetent. I was wrong. I was lazy. She might as well have been a rabid dog, teeth deeply seated in my torn flesh. I responded with stunned silence, then exhausted tears when I could safely get myself to a private bathroom.
I remember no one in the vicinity saying a word. No one stood up for me, not even the internal medicine staff doctor who I directly reported to. He simply stood by and watch this unfold. No one stepped up. No one. I was alone and like most days in the previous two years, not good enough. Reflecting later, I wasn’t sure who I was more disgusted with, the rabid hematologist or the passive internal medicine specialist.
Thankfully, those two doctors are now retired. They are no longer able to traumatize other learners as they did me. Yet, unfortunately, I know if I was affected the way I was, there are many more students and residents who were affected similarly, with their own incidents, by staff doctors who were “supervising” them.
I carry a bit of shame around not speaking up at the time. If I had, perhaps small changes could have been made to protect trainees. But at the time, I was scared and felt like I was in a powerless position. I just wanted to get through the next year so I could find a place that wasn’t so mean.
And so, the bullies won. Are they still winning in our medical schools?
Author Notes:
Becoming a doctor is an interesting process. Much of our learning is via on-the-job training. Yes, we are paired with specialists in each field. Yes, these specialists are considered experts and know what they are doing medically. BUT, most are not trained teachers. Most do not have education degrees. Most have no training in how to educate. Some shouldn’t be allowed to educate.
I have hoped over the years that things got better for our trainees compared to when I was in their place. I think this is probably true in some areas. But other areas might be lagging. It’s such a tricky space to navigate – needing to learn all the things, not feeling like you have a safe place to raise concerns, putting up with shit – so much shit!!, not feeling like you have a voice for fear of losing that coveted residency spot or being black-balled as a “complainer”. Are we doing any better now with workplace psychological safety? I’m not sure.
Though my experience above has little to do with actual medicine, it has everything to do with it. I will never treat a trainee the way I was treated. We should be looking out for, not down on, each other. The first place we should learn this is in our medical schools and residency programs. We must build training environments where we lift future doctors up, not crush them to near asphyxiation.
Be kind.
Encourage change.
