By Dr. David Scales
“What kind of gas do we use for laparoscopic surgery?”the surgeon asked me. It was my first laparoscopic surgery ever, during my gynecology rotation in medical school. We were inflating a woman’s abdomen for a tubal ligation, “tying her tubes” to prevent future pregnancies.
“Carbon dioxide,” I answered, having brushed up on this the night before.
“What color is the gas tank?” he asked.
Hmmm. Different gases have different color tanks? Clearly important, but it had been in none of my preparatory reading. I stared at him blankly, my own color draining from my face. I tried unsuccessfully to peek at the tank.
“Grey,” he said, deadpan. “What color is the oxygen tank?”
Blank stare again.
I was being “pimped” — asked to instantly recall medical facts (“pimp” is said to derive from the acronym for “put in my place”). My supervisor was proving his point: Not knowing the different tank colors, I might not notice if someone inflated an abdomen with oxygen, potentially causing a horrible explosion when a bleeding vessel was cauterized.
It clearly left its imprint — this happened in 2005. To this day, I remember that green is oxygen and gray is carbon dioxide. But it was also humiliating: How could I possibly have anticipated his line of questioning?
This week’s Journal of the American Medical Association has a panoply of articles on quirks of medical education like pimping. The studies raise serious questions and concerns about the health and well-being of medical students and doctors in training. Taken together, they raise one of the loudest challenges yet to the age-old medical culture of “no pain, no gain.”
• One article reviewed “pimping.”There is little research to support doing it, despite its widespread use. The authors call for more studies to examine the possible benefit of “benign pimping in the Socratic tradition.”
• Another article finds that around 29 percent of medical residents meet the criteria for depression. As a third-year resident myself, my first response was: “Only 29 percent?” In my personal experience, burnout and depression are rife among my friends and fellow residents.
• A third study analyzed drawings that medical students produced in a “Comics in Medicine” class. It found that nearly half depicted what were euphemistically called “imagery derived from the horror genre.”
Students drew supervising physicians as “fiendish, foul-mouthed monsters” and surgeons, who are notorious for brusque demeanors, “as devils, demons and even land sharks presiding over their dark confines with aggression and violence.” (Check out their comics here.)
The authors of the “Comics in Medicine” study ask: “What is it about current medical culture that lends itself to horror tropes and to such stark feelings of dehumanization from those who represent the profession’s future?”
To which I respond: Do you really need to ask?
The answer is all around us.
For example, my fellow resident, Elissa Poorman, told me about when she was pimped as a medical student. The head surgeon in the operating room asked the resident who supervised Elissa which artery supplies blood to the pancreas. The resident gave the wrong answer. The surgeon looked to Elissa.
She was stuck. Should she provide the correct answer and make the surgeon happy but make her resident look bad? Her resident was her opening to patients and could make her life difficult if she got on his bad side. “I kind of froze because I knew the answer, but I didn’t want to pile on,” she told me. So she stayed silent. ”We just pretended it didn’t happen.”
How pimping is done and these other day-to-day dilemmas are part of what’s called medicine’s hidden curriculum, “the commonly held ‘understandings,’ customs, rituals, taken-for-granted aspects of what goes on” in medical training. Unspoken things like pretending you don’t know an answer to a question so you don’t make your resident look bad. Despite calls for reform of the culture that perpetuates medicine’s hidden curriculum since 1998, the recent JAMA studies show just how prevalent it still is.
And things might be getting worse before they get better. Let’s take another recent example: This week, NPR reported on the iCOMPARE study looking at restrictions on the number of hours a medical resident can work continuously, comparing 16-hour shifts against 30-hour shifts.
In 2009, I did 30-hour shifts every fourth night for four weeks. While I got one to two hours of sleep each night on call thanks to my senior resident, some of my worst behaviors surfaced after those long shifts. I lashed out at innocuous comments from nurses, had little patience for reasonable questions from patients, and found myself tearing up at sappy fast-food commercials. My wife — also a physician — even developed a tongue-in-cheek name for it: “post-call sensitivity syndrome.” I ended up in a state where I was barely fit to take care of myself, let alone patients.
And let’s not forget the 40-minute drive home after those shifts. One reason that medical trainees were restricted from 30-hour shifts was a landmark 2005 study finding that residents driving home after long shifts were 16 percent more prone to car accidents.
Other occupational injuries like needle sticks are also more common when doctors are sleep-deprived. One famous study showed that sleep deprivation can cause more cognitive and motor impairment than alcohol intoxication (there’s a great graph here). I was essentially driving home drunk after those 30-hour shifts.
So while iCOMPARE is a study couched in the language of science — claims that we don’t know for sure what is the best for residents and patients — to me, it seems clear: The “current medical culture” wants to reinstate 30-hour shifts for medical residents.
The study authors would argue that shorter shifts are problematic because they mean doctors do more handoffs, passing their patients to fresh doctors. That moment of communication is where information can get lost, mistakes made and crucial details missed.
Oddly, however, despite multiple studies on how doctors can get better at handoffs, the study is not looking at how hospitals are teaching or handling handoff procedures.
Moreover, what iCOMPARE measures will not capture the entire story. Currently, the study plans to report on patient mortality and resident education. But it does not measure the depression that long-shift residents are bound to face, the burnout they will struggle through, or the drop in their quality of life and mental well-being.
And finally, these studies might not even be ethical.
As reported by NPR, the American Medical Student Association and Public Citizen raised ethical concerns in a complaint to the federal Office for Human Research Protections. That’s because the residents and patients did not provide “informed consent” to participate in either of them.
Imagine a study of sleep deprivation in airline pilots at two airline companies. At one, pilots will stay up for 30 hours straight. At the other, pilots can’t work longer than 16 hours. To see which shift regimen is better, they’ll measure plane crashes.
Now tell me, when buying your ticket, would you want to know which airline had the 30-hour shifts?
My supervisors have “back in my day” moments talking about their own challenging residency experiences. One role model even likened her training to the Marine Corps.
Sure, medical culture has gotten better since then. Gone are the days of 120-hour weeks and surgeons throwing sharp instruments at people in the operating room.
But there’s still a long way to go. By continuing to “pimp” trainees and push residents to work 30-hour shifts, the current culture of medicine is still teaching the hidden curriculum that doctors must sacrifice everything to pursue a career as a physician.
There’s no need to ask why trainees are depressed and depicting their supervisors as demons. We already know the answer.