The Hypocrisy of Medical Education
[Applause]
my life as a medical student is pretty
much exactly what you would expect
most of my day is spent studying
complicated diseases and complicated
symptoms as well as even more
complicated terminology like
sphenopalatine ganglia neuralgia or
colitocholithiasis
i mean come on let’s face it if you’re
not frantically googling the
pronunciation of whatever the heck this
is before presenting a patient to an
attending
are you really in medical school
and admittedly like most 20-somethings i
spend a significant amount of my day
engaging with social media
now to be fair this really only serves
me one purpose
giving my brain a break from all the
studying by laughing at memes
in many ways memes have become a sort of
universal language among young people
they effectively portray and communicate
cultural expectations social norms and
current sentiments
so for the purposes of illustration i
thought i would pull just a couple of
medically related memes made by students
and physicians alike for you all today
so here’s one
now i think a lot of students would
probably laugh at this meme or at the
very least they’d probably relate to it
on some level
memes like this give both creators and
consumers a sense of solidarity a sense
of
hey yeah maybe this experience is hard
but at least we can all acknowledge it
and laugh about it
even so let’s not glaze over some of the
darker undertones being portrayed here
because every day i also see images
similar to this one that portray the
unhappiness of students and residents as
they brave a happy face
and work long sometimes 30 plus hour
shifts while also silently battling
their own demons of depression
burnout and anxiety
so yeah these memes might be funny and
we might laugh about them privately but
the reality they’re alluding to isn’t
funny at all
the internet hosts yet another symptom
of a deeper syndrome the so-called
medsperation pages now here ideas
probably otherwise thought of as toxic
have become normal expectations for many
students
expectations that studying should be the
only priority in your life that all
personal relationships must go on hold
until after your medical training
concludes
that you must literally suffer to
succeed you must deprive yourself of
sleep
food and exercise in order to achieve
your goals
now these aren’t funny in the slightest
and i really don’t think there’s any
covering up this very clear message
in order to be a successful physician
in order to take care of other people
you cannot take care of yourself
now this disturbing ideology certainly
extends beyond the internet into
everyday life and the effects of it
aren’t subtle either
i call the consequences of this ideology
the inflammation effect in medicine we
understand that negative health
consequences aren’t always caused by
acute injuries or diseases
rather
low levels of inflammation so low
they’re probably not actually even
noticeable to the patient over time can
grow larger to have devastating
consequences
this erosion of well-being is happening
within the medical community on a
cultural level
small daily behaviors like bragging
about how much you study how little you
sleep
or the classic oh my gosh that exam was
so hard i only got a 90 percent i’m
never going to get a good residency
well those are the inflammation and
we’re exposed to them
constantly
just recently i saw an instagram post
from a student on their surgical
rotation proudly proclaiming i haven’t
slept in 36 hours if you’re not grinding
you’re not running
i don’t know about that
okay so sometimes you have to work 36
hours i understand that but you’re
bragging about it
what is this something we brag about
i’m supposed to be impressed
once i started noticing this
inflammation i couldn’t stop seeing it
and it really started to bother me
this wasn’t something i had noticed in
undergrad so
what had changed
over the course of the past year i made
it my mission to get to the root of this
problematic culture
it’s a really interesting and also very
frustrating phenomenon i would ask a
group of classmates about how they
perceived their performance as a medical
student and as long as there were other
people around they would say things like
oh well you know if it were easy
everyone would do it or it is what it is
but one on one the truth would come out
they would tell me how unwell they felt
how burnt out they had become and how
little they felt they could trust their
peers because
they’re who i’m competing with
actually privately every single person i
talked to acknowledged that there was a
toxic culture brewing but no one dared
to admit it publicly
so the first thing i wanted to know was
whether this inflammation was localized
only to my own medical school to find
out i reached out to students at several
other medical schools all across the
united states i asked them about their
school cultures as well as their own
personal and professional motivations
and experiences within the medical
education system
here’s what i found out
ninety-one percent of students felt as
though medical school was academically
challenging
no
82 percent of students felt daily
pressure to study
65 percent of students cited peer
pressure as a major motivator for their
studies
and 73 percent
don’t discuss their grades study habits
or class ranking with others
now these numbers didn’t really surprise
me of course medical school involves
lots of studying and i think it’s really
reasonable to expect students to work
hard when they perceive their peers to
also be studying hard
i did wonder however if this amount they
were perceiving actually aligned with
reality
well no unsurprisingly it doesn’t and in
fact on average students are
overestimating how hard their peers are
working by about 30 percent further 39
reported feeling inferior to their peers
and 63 percent
reported feeling guilty if they didn’t
study for a certain amount of time each
day
but here’s the most disturbing statistic
22 percent of students i surveyed
reported that they engaged in what i
would call manipulative or malignant
behavior which included things like
withholding helpful resources from
classmates lying to them about
instruction times giving them
intentionally falsified notes
or speaking ill of them to residents and
attendings
now this isn’t the majority of students
but i do fear that it’s enough to have
serious consequences for everyone
manipulative behaviors like this result
in widespread distrust within student
communities which only further
exacerbates the already warped
perceptions and feelings of inferiority
felt by so many
even physicians have told me about the
passive aggressive or sometimes
blatantly aggressive behaviors that
often permeate hospital hallways
one resident told me about an old
medical school classmate who actually
went so far as to put mouthwash in the
contact lens solution of a colleague in
order to mess him up before an important
interview
bad i know
so why are we doing this
how have we gotten to the point where
stepping on each other to propel
ourselves to the top
is not only acceptable
but normal and maybe to some degree
expected
there are two ways to view the origins
of this toxic culture one is the result
of several systematic issues and one is
a more individualized issue
let’s start systematically
by 2032 there will be an estimated
shortage of 122
000 physicians in this country
to combat this medical school admissions
have risen 31 since 2002
and yet available residency positions
have not risen to meet this increased
demand
which means that finding necessary
postgraduate training has become much
much more competitive
on top of that it’s also worth
mentioning that in 2024 the average
graduating debt of a medical student
will exceed 300 000 dollars
so of course as far as we students are
concerned this all sets off a bit of a
panic we’re spending decades of our
lives and hundreds of thousands of
dollars on our education and yet it is
increasingly unlikely that we will be
able to find desired residency
placements upon graduation
all while millions of americans continue
to suffer from lack of access to health
care
of course students feel pressured to
compete and do well
but still let’s not all forget why
medical students are medical students
and that’s to learn medicine and to
learn it well
even here we’re starting to see some
issues of course there’s always pressure
to do well but the criteria of what it
means to do well
keeps rising higher and higher
to illustrate this check out usmle step
one the first standardized national
board exam that students all take as a
proxy so as you can see here every year
minimum passing scores as well as the
national average scores are rising
higher and higher
so are students working are students
smarter
probably not
are they working harder to meet higher
expectations
yes
is there a limit to how hard they can
push themselves
i think we might be approaching that
limit now these are very intelligent
driven individuals and yet over
one-fifth of them report regular
prescription stimulant use that’s three
times higher than college students 76
percent of them report that they use
these stimulants regularly in order to
keep up with academic demands they feel
they would not otherwise be able to meet
the good news
is that we’re starting to see some
changes in start of these systematic
issues
the usmle announced that starting next
year step one would be evaluated on a
pass fail basis which is a massive step
towards driving intense testing pressure
on students downwards
further many medical school curriculums
are also implementing past fail
standards so that students are no longer
pitted directly against each other for
class rankings these are actually really
good things for the mental health of our
students and we can all look forward to
seeing more positive changes in the
future
there is however the individual piece of
this puzzle and this is the component i
really want to focus on because a large
part of the problem lies within our
community itself
the field of medicine has had a long and
tumultuous relationship with the
perpetuation of burnout culture many
senior physicians still subscribes the
idea of i suffered when i was younger so
now you need to suffer too
that idea is dangerous
if this were a fraternity that was
hazing students by encouraging them to
stay awake for days by using illicit
substances to do so there would be
outrage wouldn’t there listen we’re
already in the middle of the medical
mental health crisis as many as 50
percent of current physicians meet
diagnostic criteria for mental illness
and yet only 26 of them are actually
seeking help
they very hypocritically are doing
exactly what they tell their patients
not to do
they don’t reach out
they don’t ask for help and they’re not
making their own health a priority
tragically this means that the suicide
rate among physicians is two to three
times higher than the general population
and yet these thousands of deaths tend
to be swept underneath the rug by this
culture
students mirror these figures closely
but what’s interesting is that when they
begin medical school the prevalence of
their mental health concerns is actually
about the same as their non-medical
counterparts which suggests that it’s
the demand and drive of their education
that contributes to their decline
and just like their attendings students
also aren’t seeking the help they need
the most commonly cited reason why is
fear of embarrassment around peers
pierce
there’s that word again
this really is a largely cultural
problem not only is pure fear
contributing to the decline of many the
health of many students as well as the
perpetuation of sabotage and mistrust
it’s the serious issue that we need to
address
now many of the issues i have presented
today are
rooted in systematic shortcomings very
much out of control for the majority of
us
but they are greatly magnified by
factors that are within our control and
please don’t mistake me the point of
this talk today wasn’t to complain about
the woes of being a medical student i
knew what i was getting myself into when
i enrolled in medical school
however i’m not ignorant to the
challenges that we face moving forward
as a community
every day i watch the people i learn and
work with suffer in silence because
their voices are squelched by a culture
that encourages self-destruction and
pursuit of what we deem as
success
we cannot in good conscience continue to
stand by and justify this destruction
because
your medical education needs to be
extremely difficult
now learning huge amounts of material
can be difficult making decisions of
life and death can be difficult working
those very long shifts to see many
patients in a strained health care
system
that can be difficult
not everyone is willing or able to do
this work and nor should they be
but at the very least what i’m saying is
that being able to trust your friends
should not be hard nor should be being
able to find security amongst your
co-workers
getting help in dealing with unique
career stressors
should not be hard
feeling valued as a learner and young
professional should not be hard
it’s important that we all ask ourselves
why am i doing this
am i mentioning to my classmate that i
haven’t slept in 36 hours because i want
affirmation
sympathy
do i want to be told wow you work so
hard when in reality i should be told
dude
that’s not healthy
i have two things to ask of all medical
professionals present and future
number one
be genuine consider the consequences of
your words and actions and do not
mislead others for personal gain
if you need help
ask for help if something goes wrong
don’t say that it went well we must each
consciously work to break these
illusions of perfection that have become
so dominating in this age of technology
because listen
everyone struggles everyone has bad days
and if they tell you that they don’t
they’re not being honest with you the
more open and honest we can be with each
other about our challenges
the more it encourages everyone to work
together instead of against each other
number two
have a voice
do not stand for mistreatment do not
excuse lies or manipulation just because
it feels normal
this is a massive issue that is eating
our community internally and it’s a
problem that can only be solved
internally
remember our wellness as health care
providers affects much more than just
ourselves
now i don’t expect these changes to
happen overnight but if today we can all
agree and accept that we do what we do
for the wellness of our millions of
patients
why do we not treat each other with the
same degree of care
thank you
[Applause]