In our society in general and medicine in particular we have lost our moral compass. Personal wants have superseded our patients’ needs. Honesty, integrity, compassion, and curiosity have given way to political correctness, pleasing faculty or patients, getting wants fulfilled.
Dealing with life and death issues demands honesty. Without that judgment fails. That being said there is a big difference between honesty and cruelty.
We have become a selfish cruel society and that has no place in the practice of medicine. It once again impacts judgment.
Lastly our young people need to be able to take constructive criticism. It is essential for learning and listening.
Medicine in not about “me”, it is about relieving the suffering of others. It demands we place our personal prejudices aside and do what is best for our patients. It is uncomfortable at times. Life is uncomfortable. But it is also the most rewarding endeavor on the planet. It is a true gift to relieve the suffering of others or help them bare it.
We need to revitalize the soul of medicine, it’s magic and mystery and its heart.
1
Despite my being in a less competitive more relaxed field like psychiatry, I experienced an enormous amount of humiliation and what felt like abuse, in medical school and residency, though not at Dr Rostain’s excellent training program where I spent a year.
But American medicine has an obsession with « good » training, what magical confection of didactics and hours will create the next super race of ethical compassionate and competent doctors. Unfortunately for me this discussion seems to have begun after I finished residency.
But if a residency lasts on average 4 years more or less, and a doctor’s career lasts 40 years more or less, where do you think a doctor is learning more, acquiring more skills, and adapting to changing patients and needs? Most of our learning takes place after training. That is also where unsupervised and independent physicians do the most bad. What America really needs to do is find a way to shape the practice of its graduated physicians, not its trainees. In my field I have encountered dozens of « dangerous docs » who will never be corrected, though some will lose their license (and have). But patient harm continues.
Elite programs like Penn provide care that is not reflective (in a good way) of the care provided in the community, at least in psychiatry. What we need to do is focus on the practices of graduated and independent physicians.
1
I hate the term, but "snowflake" is apt for most modern day medical students and residents. Doing less never made anyone more competent.
1
Interesting article. But there are far greater fault lines of this Medical Culture than students' success in adopting PC sensitivity and sensibility.
After you explore all the nooks and crannies of every medical, moral and spiritual ambiguity, you find "one-size fits all" resides not in reality, but the wishes of idealists preoccupied with purity. The great divide of politics has infected Medical Science.
One side, the "Science" side insists we should strive for purity by creating regulations that dictate what is right. Then we measure and digitalize this rightness, excluding those who fail to conform this standard.
The other side sees Medicine as too complicated to make absolute rules for every event and action. Real life is not pure, but messy. We are drowning in information. What we need is wisdom.
Unlike politics, the Culture War in Medicine remains hidden because one side owns the Voice, the informed "Science" side. Few appreciate we have controversy here with no conversation.
2
A serious question. I graduated from medical school in 2007. Does that count as the bad old days or not?
Nope. Bad old days were well before the millennium
Perhaps part of interviewing for medical school should include questions such as - will you be comfortable delivering care to patients whose lifestyles you don't necessarily agree with? And Are you comfortable counseling a pregnant woman on abortion when a) the pregnancy is detrimental to her physical health
b) the pregnancy is not viable
c) The patient might consider terminating the pregnancy?
Better to understand what is expected before starting the process. There are so many qualified candidates who don't get into medical school, there is no reason schools shouldn't be able to take people who are willing to do what is needed.
4
In reading the article, I was struck by how some trainees complained about learning to care for transgender patients or cited personal religious convictions when not wanting to discuss termination of pregnancies. My message to these students is that it's not about you, it's about the patients and what they need and desire. If you can't separate the two, and try to treat people based on your own values and prejudices, maybe it time to find another profession.
22
"In a previous position where she was doing adolescent medicine, Dr. Gold said, she had experiences with medical students who said they had religious objections to advising pregnant patients about the possibility of terminating pregnancies."
I'm strongly inclined to think such people should not be doctors at all. Medical advice from a doctor in the modern world should (must!) be based on the latest medical knowledge, nothing less. What Zeus, Neptune, Athena, Moses, Jesus, Mohammed or Krishna might have thought of the case is utterly irrelevant.
Such teachings might inform the patient's decision about what course to pursue, it's their life after all, but doctors should not be giving advice that is skewed by whatever mythologies they were taught as children.
20
Couldn't agree more with this piece. I'm reminded of a recent seminar announcement in my department email inbox; the title was "Providing feedback to millennials".
I have a leadership role (thankfully not training program director...) in a subspecialty Medicine division at a major teaching hospital. Over the last 30 years or so our training program has produced several university presidents, several deans, multiple chairpersons of Medicine, and >100 division chiefs, not to mention investigators who've made truly seminal contributions to our field, many from our Division. We have 10 trainees per year, in a 3-4 year program - one year clinical and 2-3 research.
My subspecialty has become less popular of late. To the point that every 2-3 years we have one clinical year trainee who doesn't quite make the grade for one reason or other - be it behavioral issues, organizational problems, lack of knowledge, procedural disasters, you name it. It hasn't tracked with educational pedigree - I can think of at least one Ivy League MD/PhD trained in "the best" medical residency whom I'd not trust to treat a hamster.
What's been fascinating to watch is the blow-back that "whistleblower" attendings are subject to when they alert our program to substandard trainees. Even with a major cultural shift and a greater emphasis on our "clinical competency committee", I was subject to vicious feedback this year when alerting everyone to our latest "007" (license to kill....).
3
As someone who was trained in the 1970s when I had almost no female attendings or residents, I was subjected to hazing and bullying by a minority of superiors- residents and attendings- which made a truly difficult time even worse. Their behavior was accepted and even admired by some, but never helped me learn. In order to make to tolerate working with bullies, I chose to reject following the unspoken rules. This macho atmosphere was damaging to students (male and female) and patients. It's not just a matter of not hurting feelings. It is a matter of respecting everyone, no matter the gender, generation, race, country of origin, or even specialty. I totally reject the idea that I turned out to be a great doctor, so it must have been a great system. We need to keep working to improve how medicine is taught. Residents and attendings are teaching with zero training in how to teach, much less how to give constructive criticism. We learn by see one, do one, teach one, which falls short of what is needed. Needless to say, we all need to have somewhat thick skin and we all need to have the grace to forgive people for bad behavior under intense stress.
11
I'm currently a medical student, and I'm frankly surprised that this article was published without a single quote from a medical student or a resident physician.
Much of the apprehension we feel about "negative" feedback is directly tied to the hyper-competitive nature of our training pipeline. Ironically, thousands of medical students submitted applications to residency programs earlier today – the viewpoint I often encounter among my peers is that any negative feedback, which makes it into an evaluation or a dean's letter (however benign) is just another reason for a residency program to gatekeep and potentially end your career in medicine before it even begins.
Along with the WSJ op-ed published a few days ago, the Academic Medicine editorial chiding that we'd "binge watch Netflix and compulsively post on Instagram" if the specter of high-stakes, scored board exams were removed, and other commentary, I can't help but wonder – why is everyone piling on medical students? I've found that my peers are eager to learn, resourceful when thrown into new environments, observant of their surroundings, curious about the future of medicine, and incredibly tolerant of others.
We want good feedback. We want to be better doctors. Please work with us to make medical education better for our patients.
17
Bravo! I trained in the early 1980s. I have never forgotten a single mean thing that an attending said to me as a medical student or as a resident. It can be soul crushing and make it incredibly difficult to gain the kind of confidence you need to make important decisions for a patients health care.
5
@VK the comment about students binge watching Netflix instead of studying if high stakes board exams were removed is ridiculous. I’m a medical student in Canada, where we don’t have high stakes board exams and medical school is pass/fail, and everyone still studies hard.
2
Abuse of power is an inherent risk. It can’t be legislated away.
Nor is it limited to men, contrary to much of what we read (increasingly on the ‘news’ side of the organization’s output) in the New York Times.
4
I'm a Professor of Psychiatry and Pediatrics at Penn. This is a very thoughtful piece. I agree with the main points and the thrust of the article and am now prompted to read the JAMA Pediatrics article as well. My sense is that there's more to this than just "learning how to give feedback" - although this is certainly an important skill. We also have to consider how young people are being raised nowadays to see all negative feedback as threatening ("destructive perfectionism" is the term we've been referring to in our work with college and university students). There are also major changes in the structure of medical education that have led to the diminishing of faculty-student face-to-face encounters that enable trusting relationships to develop. I was intimidated by some of my professors at NYU Medical School/Bellevue and during my residencies at CHOP/Penn, but at least I spent hours with them on rounds, by the bedside, interacting with lots of patients, colleagues and hospital staff. Medical education has been drastically altered by the system-wide changes in health care delivery (including shift work, reduced teaching rounds, EMR and inordinate discussion of the "bottom line" that leads clinical educators to be less available to trainees) and we need to consider how "walking on eggshells" is a reflection of the undermining of close working relationships that used to be the hallmark of medical education back in the "bad old days."
11
@Anthony Rostain
You are right on the money. The best book I have read in the past year is “The Coddling of the American Mind,” by Lukianoff and Haida. It chronicles the emergence of a student culture in which faculty have to be exceedingly cautious about causing emotional distress in their students based upon the myth that students aren’t resilient, and a culture in which divergent/controversial viewpoints are hushed rather than confronted in open debate. It is also true that events causing stress are remembered more vividly. So, if a faculty member lays into you for not preparing adequately for a surgery, or not thinking clearly about the best antibiotic regimen for the patient you admitted in the middle of the night, you are more likely to remember it and not make the same mistake the next time. My mentors didn’t spare criticism, but I loved them and I can return to warm greetings 24 years after the completion of my residency.
4
I'm not surprised this has come up again, but I am very frustrated. Pauline Chen, whom I otherwise greatly admire, wrote a similar column several years ago and it is as telling then as it is now that this is the topic prominent physicians focus upon.
Medical students aren't able to do very much, and what they are able to do is a result of teaching from those further advanced in medical training. What always stuns me is the unspoken expectations that we're all supposed to know when we start a new rotation, new training, new job, etc. There are so many rules I didn't know at my new job that my old one didn't have, and I was breaking these rules all the time without knowing it. This is the constant state in which medical students live, and they're only starting out in their medical careers. Being treated with disrespect is unfortunately part of being a medical student, and even a medical trainee, though the degrees of this vary from institution to institution.
As a result of this, feedback just becomes negative blanket statements or implications -- often, it's not even verbalized but it's clear that you're no good. This "feedback" isn't timely, constructive, or offer ways forward to improve. I would wager that it mostly stems from a dearth in teaching on the part of the one giving feedback. Feedback is extremely important, but it often just serves to make the giver feel more power in the hazing role than help the receiver improve and become a better doctor.
3
I am a practicing Ob-Gyn who has seen the entire transition, from the unlimited 36 hour calls to the more limited 24 hour calls, to the very restricted training we have now.
Yes, things may have been a bit extreme at times. Maybe the hours could have been adjusted a bit. Maybe our seniors could have helped us more when we were junior residents.
We were all grilled to no end by our attendings and senior residents.
Now the tide has changed, but is it REALLY for the better?
What is forgotten among all of the niceties of the new training and new residency rules is that we all had excellent training, UPON LEAVING RESIDENCY.
When I completed residency I could look to my left and right at any of my colleagues, and trust them with surgery on a relative of mine. I could easily say the same about surgery, medicine, or radiology residents that came out of our hospital system in the Bronx. Can any of the new grads say the same thing now?
Be honest with yourself, based upon what you see around you.
Will you blindly trust a CURRENT graduating resident with surgery or a vaginal delivery on a family member of yours?
Residents graduate from programs and they are not 100 percent sure how to perform a basic cesarean section. Most are not comfortable making basic management decisions. Most cannot perform a basic hysterectomy without the assistance of a much more senior partner. And a vaginal hysterectomy? forget it.
Our training was tough, but it made us into the doctors who we are today.
16
Yes. I trust any one of my recent grad colleagues with my life and the life of my loved ones. If you doubt the skills and knowledge based competency of graduates of your own program, the strength of your didactics and boards prep should be evaluated, not whether or not you've done enough hazing or sleep deprivation of your trainees.
15
@Ob-Gyn MD,
Scarier still is the ability of new attendings in critical care settings in the middle of the night. When folks are removed from the protection of work-hour restrictions as residents, and find themselves working longer hours than they are used to, in high stakes situations, patients tend to suffer.
Further still, while everyone needs to be treated with dignity, trainees need to be told bluntly when they are not performing well, especially in high stress environs like ICUs and ORs. Feelings need to take a back seat when lives are on the line.
3
I am a fourth-year medical student. I have many thoughts on this article.
One of the issues with receiving feedback is that we are both trained and evaluated by the same people. Students are particularly sensitive to negative feedback when it might appear in their clerkship evaluations, which can derail us in the increasingly competitive residency application process. Feedback would be more ideally be received from a person in a coach or mentorship position, rather than someone grading you.
Secondly, the amount of direct observation I have received in medical school is pathetic. A lot of the feedback we receive is generic - “great job” or “read more” - because we simply have not been observed long enough or often enough by the same person.
Finally, PC culture plays into this. Faculty and residents may be overly cautious about giving honest feedback because they worry about appearing sexist or racist.
On the other hand, they should be concerned about giving feedback that might not be PC, because it does happen all the time. My female classmate was told that her speaking voice made her seem immature. A black classmate was told that he did a good job connecting with minority patients.
It’s a mess. But speaking for myself, I desperately want honest feedback, because I want to be a good physician. Even if that feedback hurts. In a perfect world, we could have a transparent dialogue about they might help them give more effective feedback and help me become a better doctor.
8
@K That's an interesting observation. It seems like you need more "formative" rather than only "summative" assessment, in the teaching jargon, ie more assessment that allows you to understand your own progress without it being taken as reflective of who you have become as a physician at the end of your training.
I'm a relatively new and junior part of a pre-clinical (anatomy) teaching team, and it's interesting to read more about how the clinical years are handled. I've found that pre-clinical education has gotten a lot of attention from educational reformers in order to respond to theories of teaching and learning and build clinical relevance. I wonder if the time has come to go at the clinical years more.
This is just one example of our changing social norms, where children are coddled and raised to be homogeneously ‘perfect’, across all demographics and industries. The bell curve is gone, and criticism is unacceptable, replaced by endless praise and an ‘everyone’s a winner’ culture. I’m a doctor, working with millennials, and raising two teens; to ensure my own children’s health and livelihood, I’ll continue to fairly judge, and respectively critique. We all need to understand the importance of cultivating grit.
7
@Gen X have you ever considered the demonstrable fact that those who in the generation that follows you are, on average, smarter, more compassionate, less biased, more well-rounded, and better adjusted than your generation?
3
@Andrew @GenX
As a gen X I agree with you that in many ways this generation is “more compassionate, less biased, more well-rounded, and better adjusted” than my generation.
My generation in many ways were “work horses” and while I did what I was told and grew thick skin many “teaching techniques” marked me rather than taught me.
I am a Fellowship PD so I can get away with higher expectations and frank conversations. I also work with residents and medical students and it is a learning in progress how to provide the same learning and constructive and timely feedback and not the hazing that I have received. I have had amazing mentors from whom I learned medicine and research but some of the same people have taught me how NOT to mentor
The only thing I wish this generation could learn better is how to be a good mentee as that is an important skill... Yet that too is our responsibility
@Andrew
Proof?
2
I think the real issue here is common to many highly paid professions (business, law, etc.) and has been around for a long time, and seems to be caught in a perpetual cycle. First, there is a general presumption that the younger generation is lazy, doesn't want to learn, is too sensitive or demanding, etc. and "has it easy" (a view further perpetuated by articles like this). Meanwhile many (but of course not all) of the older generation doesn't really want to take the time to truly teach, and adopts a mentality that "well we went through it the hard way, so they can too." And the problems just persist.....
-From someone in the middle generation
11
As part of the old school of medical education ice suffered through my share of criticism which actually made me stronger and self aware. Obviously this shouldn't be too personal,but sometimes I think these kids are too sensitive. We all make mistakes and make foolish statements.Living through these things and dealing with them makes you stronger. Patients are there because they are in need ,listen to them even if they are rude.
7
Religion should stay out of the hospital. If those residents are so sensitive to the idea of abortion that they are unable to perform their job and merely talk about it, or to even be in the room while somebody else does (seriously?!?), then I'm sorry but this is not the right job for them. People who put their personal ideology before hospital protocol and their patients' rights and well being should not be allowed to be doctors.
71
@Nefertiti. I agree, but that will never happen. I suggest that trainees who do not learn all aspects of medicine and practitioners who do not offer all aspects of their specialty should have a clear designation. An idea would be that such physicians would be designated not as MD but as MD-R (R indicating restricted.)
Same goes for clinics, hospitals etc.
19
Yes. MD-R, where R stands for "Refusing to do their job"...
It will never happen if we continue to allow them to get away with it. We need to grow a spine, not duck out of responsibility. It's in the spirit of this article, even. Sorry guys, might be tough to hear, but you need to actually do your job if you want the job.
18
To Bob, in NY:
Sexism, racism and microaggressions are not "buzz words" they are real and damaging entrenched manifestations of white patriarchal culture. (bell hooks would say white supremacist capitalist patriarchy) If you do not see this, not only are you damaging your students but also your patients.
People who are privileged to be in the dominant culture don't see the water we swim in. It takes intent, humility and empathy to unlearn harmful attitudes and behaviors and I encourage you to incorporate anti-racism and anti-sexism (and others,,,anti-ageism, ableism, transphobia, etc) into your teaching.
18
@Susan As a medical doctor who was trained in Europe back in the 1980s, I am baffled by your tirade about the "white supremacist capitalist patriarchy" which has precious little to do with the real issues at hand. Yes, I know that this "patriarchy" is the current dominant ideology in the US which tries to explain all social problems with sexism and racism. Many Europeans find this explanation not only provincially simplistic but also counterproductive.
Of course race and gender are important factors yet their significance is minuscule in comparison to the socioeconomic factor. In my view, the obsession of US scholars and politicians with the former factors is predominantly Freudian, i.e. psychological in nature. The approach found in Europe is mostly Marxist, i.e. based on economics (addressing the latter factor).
We all know which one of these two approaches works better in terms of achieving higher level of social equality and opportunity, including equality between the sexes and along racial/ethnic lines. (By the way, many EU nations, like Germany, have larger % of their population being foreign-born than the US).
Interestingly, as pointed out also even by the NYT some time ago, history shows that the place where women have achieved the highest level of equality was under totalitarian socialism - the former East-block countries. The West still has a long way to go to reach that level and freedom and opportunity. Marx works. Freud doesn't.
2
@Susan
“People who are privileged to be in the dominant culture don't see the water we swim in.”
Your statement is a judgment in and of itself. Sorry, you loose.
5
Missing in this article and in the current training of future health-care professionals is concern about the patient. Future patient's and their health-care should come before any other consideration. I'm truly sorry that some students are offended by some parts of the profession that they aspire to join, but that's beside the point...the first consideration of any health-care professional should be to their patients and their patient's needs, not to the comfort of the doctor or the student. If a student is offended by some part of actually working as a doctor or nurse, they should not be in the health-care profession.
24
My mother always wanted to be an RN, and after many years of work she made it through school and fulfilled her dream.
I was not enthusiastic about a nursing career when I was younger, despite my mother pushing me in that direction when I started college. The idea of emptying bedpans and dealing with bodily fluids was not something I wanted to do.
Eventually, when I saw different opportunities in a nursing career, I was ready to take on all aspects of it, the good and bad. I have not regretted my decision to become a nurse, but I am glad I waited until I was ready to deal with every aspect of this profession. As it turned out, bodily fluids are the least of it.
If a medical student is not ready to deal with all the responsibilities of being a physician, then s/he should choose another profession. It’s a tough job and you don’t have the luxury to pick and choose which patients and illnesses you want to treat once you have a medical license.
2
As a medical educator (program director) the pendulum has swung too far. Most feedback is edited in order to assure that no one is offended - because there’s always the looming threat of someone complaining with buzzwords like sexism, racism, micro-aggression, etc. Just a complaint can be career ending these days.
Trainees also have a lot of power to compromise the training programs by submitting negative reviews to the Acgme, whether warranted or not. So necessary remedial action is often avoided in fear of retribution.
Medicine is an institution and perhaps there’s something to be learned from the generations that came before.
The current startup generation entering medicine feels like its up to them to re-invent the wheel and the parameters for telling them otherwise have become particularly narrow.
This is a classic case of the tail wagging the dog.
It goes without saying, All people should be treated with consideration and respect, period.
27
@Bob not a programme director but I often give feedback to students and trainees and the reason everyone sanitises their feedback is because we dont teach how to give feedback. Currently the overwhelming majority of feedback is negative and when things are going well no one says anything at all. So the moment anyone says “can I give you some feedback” you are automatically on the defensive.
I chat to my trainees about a lot of things positive and “negative” - it’s rare that something they have done is truly dangerous or negative but by constantly having conversations about aspects of practice that I think are really good, those that are fine but not what I would do, or thing I really recommend they drop and exploring the reasons for why they did x or y I can have conversations with them about when things don’t go to plan.
Sometimes things I have watched them do that seem really weird have a really good reason for why that student is doing something. And I have learnt heaps from asking rather than jumping in with my interpretation of what I have seen.
I think students don’t want to “wag the dog” they just want to learn and get useful feedback. But if their trainers say nothing to them through an entire placement and then spring negative or bland feedback at the end with no means of reply or remediation it’s no wonder they get upset and complain. Even single bad feedback for students can disproportionately disadvantage them.
1
The watchwords of the decade.. support, feedback, ad infinitum.
Just as a comparison with medical schools (if the two can be contrasted at all), in law school, there is nothing but negative feedback, if you get any feedback in the first place. In true Socratic fashion, ask a question and the response you get is just another question. In one class, there was a discussion over a single paragraph for 4 days because the professor refused to provide an answer. Students were required to think for themselves. Confidence built as understanding and abilities increased and not because anyone received 'feedback' to bolster a flagging ego. Grades for a year-long class are not provided until the very end of that year with no feedback whatsoever of how you're doing along the way. The belief is that if you have to ask for feedback, then you're probably not doing too well. Also, when attorneys are working on cases, no one ever gives them feedback until the case is closed so why should students expect feedback before completion of the course?
These medical students sound as if they are emotionally unstable and have no inner strengths to rely on as they interact with other professionals. That is a sorry state of affairs which has become rampant throughout our flailing American culture. People just won't stand up and face adversity these days. Instead, it's just easier for them to whine for support and feedback.
8
Residents steeped in hubris and left to care for vulnerable patients without appropriate supervision are par for the course at Harvard Medical School's oldest and largest teaching hospital. I'll never forget how one them shrugged after botching the care of my elderly mother in the ED. Her life meant nothing to him. It was chilling and unforgettable.
27
Oh come on! Medical students appreciate negative and constructive feedback, so long as that's not the only feedback we get! If you're gonna dish out negative feedback to a medical student, you better be a decent enough teacher in the first place. Did you, as the teacher, give the medical student opportunities to learn? Were there enough teaching sessions, teaching rounds, and instances where the medical student got to practice clinical skills or given responsibilities to grow?
Negative feedback != hazing, which is what the past generations went through. If all you do is berate medical students, without either giving them opportunities to grow or learn from their mistakes, then all you end up doing is abusing people. One of my favorite attendings in medical school was someone who regularly gave me negative feedback. However, that same attending gave me responsibilities and taught me many clinical skills during my rotation. I ended up learning a lot from him.
27
@Local Labrat... Did the teacher/professor give the student an opportunity to learn? If the student was sitting in class, that's the opportunity. Or standing alongside a professor as they observe a patient? That's an opportunity.
And you learned a lot from negative feedback!
4
@cynic2
Some attending physicians never do go to the same bedside as their student. Some never do provide a lecture, teaching session, or reading assignment but complain about the students' fund of knowledge being poor. Some never state their expectations & then berate the student for not knowing what to do because "that's how it's done," even though their colleague did it differently last week. Seriously, this happens
14
@S This happens way more often than you think! And lectures in pre-clinical years are often very different from what knowledge is expected in a clinical setting.
9
Why is this news? As a professional trainer in health care, I designed a curriculum called “Critical Conversation”. It was the train staff to give helpful, and required, feedback to medical staff. It was helpful, appreciated, and a few docs contacted me years later to ask for the syllabus to use in their new positions . Most excellent facilities are doing this kind of coaching for leaders. It’s a different story when the issue is really: why are incoming young providers heartbroken when given feedback? THAT is a story.
8
Getting only one side of a story is dangerous in many situations, and in the medical field it’s the lives of human beings on the line. I am angered and disappointed at the bias revealed in this piece. This article clearly paints a picture of idealized supervisors encountering intellectually and/or emotionally shallow trainees. In my decade of medical training to become a physician, I experienced and witnessed countless instances of less than perfect supervisors and trainees being treated as though they were insignificant. I also worked with wonderful supervisors and less than perfect trainees. This article disastrously fails to convey the truly multifaceted nature of this environment. In a vulnerable group in whom rates of depression, substance abuse, and suicide are markedly higher than the general population, what good does it do to perpetuate toxic beliefs towards them with only one very filtered side of a complex story?Medical trainees, like patients and supervisors, can have their pros and cons as people but need to have their feelings and lives valued on an equal plane, otherwise, like anyone, they face deadly consequences. Trainees as a whole DON’T need further alienation - just look at the data. This article is misleading and dangerous. To the readers who feel angry toward trainees after reading all this - please seek out other sides of the story to improve our understanding and empathy toward each other. We need that in this world today more than ever. Most bogus.
43
@Former medical trainee of 10 years. Thank you! My son is a 4th year medical student and I am appreciative of your comment. Medical school in general is extremely stressful, there has been an increase in suicide, depression, and anxiety for medical students at epidemic proportions. Can we have an article addressing why that is? This article feels like a “pile on,” and I find it dreadfully curious why medical institutions Collectively aren’t aggressively addressing NEED FOR CHANGE- we are killing our medical professionals; students, and physicians. It’s truly sad and pathetic that a profession meant for help and healing can’t look in a mirror to help themselves. Quit perpetuating toxicity.
6
In my own medical education, I have mostly faced either a lack of feedback whatsoever or simple pain disrespect. I really value feedback, even if its hard to hear. But many departments have toxic work cultures that value negative reinforcement as opposed to respectful feedback.
24
Physicians shouldn't need participation awards. My parents were trained in the 50s, and as med school professors, I am sure they were tough on their students. But they were respected, and the students knew that whatever they said was for the students' own good. I cannot believe this is an actual dispute, but the complaining by highly intelligent and motivated individuals who are called to a benevolent service to their fellow humans reveals a level of selfishness and self-centeredness that I find disappointing. And I'm a lawyer!
16
With all due respect, have you spent a day on rounds, either your parents' or otherwise? Be careful what you wish for re: the good old days--they used to also come with zero duty hour restrictions. Residents used to work 100 hours a week and similarly, anyone who complained would also be accused of wanting a "participation award". Would you want your treating physician to have been awake and working for the last 30 hours?
18
When I was a senior resident, I introduced my function on the medical team to new members as really just two jobs: 1. To take care of the patients and 2. To take care of the interns and medical students. Being a physician is the amongst the most rewarding and demanding roles, and one simply cannot give what one does not have. If a physician does not have confidence and self-compassion, how can afford that and more to our patients?
The problem is not negative feedback -- it is lack of face to face delivery of that feedback and having the first time it is actually communicated to the trainee on a written evaluation that is part of their assessment. This blindsides the learner and does not give him or her time to actually employ the constructive criticism in practice. And it happens much, much more often than people think. Regular, weekly check-ins were encouraged at my program and for the most part this was well-received, whether there was praise or not. Timing, as they say, is key.
Only in medicine is basic consideration and respect for others' feelings -- especially when the individuals in question give up their 20s, go hundreds of thousands of dollars in debt, and spend 80 hrs a week tending to the human condition in its most vulnerable states -- up for debate. Rather tonedeaf of the NYT, especially in light of Physician Suicide Prevention Day on Sept 17.
31
I am a fourth year medical student. My biases are that I am a woman and I am liberal. Here are my thoughts: I have been the recipient of both good and bad feedback over the last 4 years. I have been given constructive criticism in a nice manner that has inspired me to change and learn, and been shamed publicly that has me embarrassed me into changing. I aspire to be the former.
When I think about walking on eggshells, I think of a situation I saw when a new third year student being called the name of another third year student of the same ethnic background in an emergency surgery in the middle of the night. She was thinking about complaining about it as a microaggression. I think if I was a non-medical person or a new MS3 student, I would have felt more empathetic towards this student, who clearly had her feelings hurt. However, at that point in my life, I had been called millions of variations of names on rotations, some close to my own simple name, some completely different. There were 10 medical students on the service that month, and in that moment, I actually felt more empathy for the senior resident who was up in the middle of the night doing an emergency surgery, and will probably be spoken to about the micro-aggression that the student brought forward.
My big takeaway from my own medical education is to treat others the way you want to be treated, to recognize when I am in the wrong, and that no one is perfect.
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@Ann "...my biases are I am a woman and I am a liberal"
Those facts about you are not your biases. Perhaps your particular features bias you against men? or against conservatives? If someone mistreats you because of your features, the bias is theirs, not yours.
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@Ann
I'd be glad to have you as my doctor.
9
That’s not micro-aggression - someone at 1 AM who just met 10 new people got their names mixed up. Stop choosing to be offended. Grow up. Show some spine. That’s life.
8
As "standardized patients" for medical students at one of the most prestigious med schools, we were explicitly told we must be very careful to not be critical and hurt the students' feelings when giving feedback. (A standardized patient acts out illness symptoms so students can learn to assess them.) While it's true that what was being tested was the students' diagnostic skills, I wondered what was behind such careful treatment. Are a patient's opinions of how a doc treats them irrelevant? Must we wear kid gloves when handling the sensitive young medical students? Of course being polite and gentle is a more humane and usually more effective way to deliver criticism. But to not criticize under any circumstances does no one, patient or doctor, any good.
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I work in an area of medicine and am in the position of giving feedback. A few years back, we, myself and my colleagues, got retrained in giving feedback. The institution called it 'Cultural competence for a multi-generational workforce' and it entailed giving feedback to our students who were of the Millennial generation. Embedded within the speaker's presentation was a warning about legal action if feedback was too challenging for the stud ETP to hear. In other words, we were being re-educated to stay quiet by our esteemed institution when the student needed the most guidance with dress, behavior, communication, and relationships in the professional setting. I wonder, then, if we risk our own careers and legal action that encumbers our progress while giving feedback to someone who lacks self awareness and desire the change from being inappropriate?
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@Heidi
Ah, interesting. Very similar to what we were told (read "ordered"). And my experience was early 2000s. So not necessarily fear of hurting Millenials, but fear by the institution of lawsuits by the students against it. That never occurred to me before but makes sense. And it is corrupt and does a huge disservice to all sides.
Criticism should never be cruel or harsh, but it can be vitally necessary to create better practitioners in any field. I guess we have to hope that the "good ones" self-police. And that good teachers still will provide wise guidance.
6
So, doctors are unwilling to consider the feedback they give might be biased? Wow, sounds similar to doctors telling themselves they aren't influenced by money, by payments from pharmaceuticals, from visits by sales reps, by speaking fees...
Criticism is one thing, but the issue is that doctors need to consider their flaws and to correct them. Doctors are no different than anyone else, and in some ways worse, feeling they can't be questioned, when in fact, they are as likely to be biased against women and minorities as anyone else but believing they are being ~objective~.
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@James Igoe
you are missing the point, although this story is about doctors it is about a generation of learners in all disciplines who want to be treated with kid gloves. and it makes the point that medical learners, must be taught.
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@Honeybluestar
No, you are missing the point. This is told from a particular perspective, without any countervailing opinion. I was just pointing out that some of that feedback is likely gender and racially biased.
- Is there any other reason that some students might feel unduly criticized.
- Might some educators be bullies?
- What degree of bias is there against women?
- What degree of bias is there against minorities?
- Does the teaching method need to be changed to better teach medicine?
Learners must be taught, but teachers must treat students like decent human beings. The assumption that medical education is somehow correct and beyond reproach is evident, when if it is anything like medical practice, it is deeply flawed.
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@James Igoe
this is an opinion article, not investigative reporting-thus a particular viewpoint. Are you saying an opinion piece must give voice to everyone else’s opinions?
Wholeheartedly agree with you that learners-and everyone-must be treated with respect. We all need to work on our implicit biases. But believe me, this generation has great trouble with even very gentle constructive criticism.
5
As an individual who is currently studying for the Medical College Admissions Test, throughout my internships in college I was thankful for the constructive criticism that I received. It gave me the opportunity to grow and mature as the aspiring and hard working physician I aspire to be. This is a field where many complex issues show up and I am going into a field where there is always room for improvement. I woke rather have an attending call me out on a mistake so that I can rectify it and never make that mistake once again. It’s all a learning experience, especially the medical field, tough skin is needed ! Don’t let what you can’t do stop you from you can do !
8
I highly recommend reading both the 1994 and 2010 editions of Dr. Klass' book, "A Not Entirely Benign Procedure: Four Years as a Medical Student", One would really appreciate what she meant by the bad old days.
Her books also tell us that being a physician (and not just training to be a physician) requires both thick skin and humility. The thick skin to let the uncalled for negative feedback bounce off, and the humility to absorb what is necessary and unpleasant to hear.
26
Respectfully, I'm not sure why an article about educating medical students doesn't include a single medical trainee or patient opinion. This is a huge oversight: by failing to consider the perspective of students and patients, who are ultimately at the center of this question about medical education, the article completely misses the mark.
37
@
because this is an opinion article, not investgative reporting or an in depth review of medical education practices
10
A little humiliation saves lives. By far my most memorable lessons at Johns Hopkins came with a burn or a sting, e.g. when I was called out for missing a routine pneumonia, or for pretending to hear a physical exam finding that really wasn't there. Never again would I make those mistakes (almost never). And I remain eternally grateful to those "tough teachers." Last month an intern here "missed" a case of diabetic ketoacidosis, and the patient didn't do well. His teaching attending went easy on him: "Don't worry about it...You'll catch it next time." With that attitude, I'm not so sure he will.
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@Kyung
I don't think either being yelled at or patted on the head leads to learning in a situation like that. A listing of the diagnostic signs/symptoms that should have made the trainee suspicious for DKA does, or a pathophysiology explanation of why it doesn't show up on the tests he ordered but only the one he forgot. Whether the attending goes over it himself with the trainee or says, "better read the review on DKA that came out in XYZ." And you can do that in many tones other than abusive.
The yelling isn't essential to learning. The teaching is.
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@Kyung
I’ve always thought this attitude bizarre.
Do you really think that resident is going to brush off that he missed a case of DKA? The vast majority of physicians and physicians-in-training have intrinsic motivation to get better and not miss those diagnoses that can hurt their patients. Browbeating someone when they are already aware of their mistake is not a helpful pedagogic technique.
- current medicine PGY1
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@Wesley Rogers
Agreed. It is fascinating that a collective group of highly educated individuals could come up so short on such a fundamental and basic human function regarding how to effectively teach, encourage, motivate, educate. Shocking the collective default has been so poor.
4
I have often thought that the way med students are treated is bizarre. My perception from the outside is there is an expectation for young docs in training to work unbelievable shifts on no sleep and operate at a high level while learning. Why? And why browbeat people into learning? Of course they need to be told when they are messing up and corrected but this should be done professionally and with the goal of teaching the student the right way. Anyone unable to take constructive criticism should not be a doctor. And anyone who teaches through humiliation is not a good teacher
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"In a previous position where she was doing adolescent medicine, Dr. Gold said, she had experiences with medical students who said they had religious objections to advising pregnant patients about the possibility of terminating pregnancies."
Religious objections should play to part in a patient's care.
What if the physician was a Jehovah's Witness, does that mean non of their patients could get a blood transfusion?
22
@Jacquie - Unlikely situation. Jehovah's Witnesses are discouraged from attending college, let alone medical school.
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@Jacquie
I think you mean Christian Scientist. My partner trained under a CS nurse, who had him and another student (they were both EMTs) hang blood for her and start transfusions because it was 'against her beliefs.' A CS doctor would have a really hard time in med school because of the interventions required, and would probably drop out, if s/he got in at all.
2
@Alyce
There is no such thing as a CS doctor -- there are CS nurses who do tend to wound care, for example, and there are "practioners" who work with patients spiritually.
That said, if a Christian Scientist wants to take medicine, take or give blood, have a baby in a hospital, or take part on any side of a medical or surgical procedure, there are no prohibitions. There is no process to kick someone out of the church. It is up to the individual. Some who are CS are quite draconian about how they view medical intervention & others accept medical help gratefully. (I did not take a pill until I was in grad school, but I was vaccinated & went to hospital for broken bones, etc.) There is (usually) no judgment. That said, if someone who was CS wanted to be a doctor, that person would likely leave the church.
4
My Mom often said “ It’s not what you say, it’s how you say it.” I think you can say almost anything to almost anyone if you use the right tone and speak politely. Speaking rudely to or humiliating a student ( or any human being )
is simply wrong. It reeks of hazing.
Medical schools are introducing empathy training in order to help physicians be better able to communicate with their patients. Don’t our future docs deserve the same treatment? It is possible to critique and correct without rudeness.
37
What struck me most during my Medical School clerkships was that none of the attendings, wether because of time or personality, had any interest in knowing me as a person. This not infrequently resulted in their being at best insensitive, at worst, sadistic. It was clear to me that attendings were expected to teach as part of their duties, but none of them had learned anything bout educating medical students. If we hope to improve medical education then we must educate the educators.
26
@Gary Swergold Wrong medical school. I attended several medical students' weddings. Female students.
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@Gary Swergold
and we attending physicians are now taught it is inappropriate to inquire about student’s lives much, because we might be seen as being biased against one or another, favoring one with background similar to ours, etc.
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@Gary Swergold
having a little trouble understanding how not learning about you in detail as a person possibly eventuates in " sadistic" behavior
Obviously any "sadistic" behavior should never be tolerated and should be reported.
7
We all have an obligation to deliver truthful feedback tactfully and fairly. Our ultimate obligation is to be honest and to work for the best in patient care. If medical trainees are so arrogant and conceited that they can’t tolerate negative feedback and improve, that’s their problem.
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@Simon Chen, MD
Such an easy slide into a bully pulpit.
I agree with a medical education that gives thoughtful, respectful, pertinent, and direct feedback. I received such as a medical student when warranted or necessary. I had the experience of a faculty member grabbing and shaking me for a minor event. The event and the “feedback” so disruptive that a member of the surgical team tore off his gown to step into the middle. A hug in the OR locker room the next morning, the circulating nurse felt badly a faculty member had stepped over such a line and it was known this is the way he teaches. A year later, knowing retaliation was the number one way this faculty group/cabal worked together... I said nothing. I just kept my distance and stayed out of his way. There cane a moment, a year or so later where I declined, politely to start a case with this same faculty person. I was called into the residency director’s office, belittled and I finally spoke up. The response was ultimately a meeting with the faculty member who had assaulted me, no third party present and he kept insisting I shut the door, “ I have things I want to say to you, and I don’t want everyone listening!” I declined to close the door and opted for everyone to hear what he had to say. This is not medical education. There were many ways to have a discourse, and a learning moment. I find that using a “carrot” versus “stick” more frequently warrants criticism has more weight when delivered. You have to engage and treat medical students as adults.
33
I am sorry to hear this story. I had a similar experience, twice, with two separate physicians. Both were male and much larger than me - I am female and I am a nurse. The first one sparked trauma and I was taught, thirty years ago, that no one would listen to a young nurse who said anything about a physician (#metoo). And the second one: I reported him and brought forward the witnesses. He was suspended and we never worked with each other again. We have gotten better. Thank goodness.
8
A generation of thin skinned, over sensitive spoiled brats who have never been told not only “No!” but “Hell No!”.
14
@Bill oh for Christ sakes. Every person over 50 has said this about every person under 30 for time immemorial. I’m sure your grandparents thought the same of you.
4
There should be more mindfulness training for medical students. This would help deal with the stress especially inherent in environments like ED or hospitalist medicine where patients are very sick and the workloads frequently very demanding. Watching patients succumb despite your best efforts and having to tell them and their families that medicine cannot or should not provide further treatment other than comfort care is one of the great challenges of practicing medicine.
Whether humiliation is a valuable part of medical training, it is not the most challenging part of medical practice.
8