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  • Writer's pictureDr. Bow Tie

Response: "Tough Love - NEJM Not Otherwise Specified, Episode 2.3"

Last week, the New England Journal of Medicine put out an episode of one of its podcasts and posted it with a headline that it was discussing the "slippery slope from 'wellness days' to inadequate medical training."


Ah..."slippery slope": the two words that, too often these days, are indicative of someone missing the point.

Dr. Lisa Rosenbaum hosts this episode and starts off by acknowledging the hardship of medical school and residency training, and then pivots to "the vulnerability of medical educators" and the "growing intolerance...of anything not considered a 'safe space.'" She then goes on to introduce her guest, Dr. Amy Holthouser. I think they both come at this interview from a place of genuine caring, but both fall into the same traps that beset anyone pushing back on progressive change.


Of note, Dr. Holthouser discusses the struggles she faced during the first year or two of our current pandemic, struggling to run a medical school from home while she had two young children and a husband with cancer and my heart goes out to her for that. It does not excuse the infantilization of trainees or gaslighting here, but it deserves acknowledgement and admiration.


Okay, so the interview was long and cycled around a few topics, so I’m going to do my best to respond to all of Rosenbaum’s and Holthouser’s points, but group them together.


Educating Trainees is Like Lovingly Parenting Teenagers

This is easily the cringiest running thread of this interview. Medical students and residents are infantilized enough without comparing them to surly teenagers. Trainees are usually in their mid-to-upper 20s or 30s, and many even older. I went straight from high school to college and then medical school and I will be the first to admit that there is a stunting of mental growth that sometimes happens as we focus solely on studying and graduation requirements. My classmates who took a more circuitous route, maybe another job or career prior to starting medical training, or who had already started families, were certainly not acting like teenagers in their training.


Attendings talk about how working as a full-time doctor is "so much harder" than medical school, residency, or fellowship.

Don't get me wrong. My job is hard. It has become more stressful over time, with increasing demands from administrators, increasingly complex hoops insurance companies make us jump through, and the onslaught of disinformation we have to battle in order to partner with patients. And I am not in academics, striving for professorship and battling to get recognized and paid for extra work I do. Still, I would absolutely rather do this job than return to the hours (nearly twice what I work now), the near-complete inability to control my hours and schedule, the pressure to court letters of recommendation...yeah, I'm much happier to be an attending, and I am not sure most attendings would say differently.


Holthouser's stance that medical training and its components "aren't the hardest part of your life" serves to gaslight (hopefully unintentionally) trainees listening to this interview. She bitterly states that "[trainees] are telling you that their perception is what you’re doing to them, by educating them and creating a structure for their education, is harmful and is hurtful" and then tosses that aside, saying that is "in direct opposition" to doctors' experience (this seems anecdotal at best). In fact, she began the interview by highlighting that medical education administrators and hospital administrators are well-intentioned and want to do right by trainees. While that is probably true, she emphasizes it in a way that ignores the impact of what trainees actually experience, even dismissing the idea that trainees might feel like no one cares about them as "the opposite of the truth." Too often those who resist sociopolitical change do this - they focus on their own intention and ignore or diminish the impact it has, even though that impact is the better measure of an intervention.


Students’ Requesting Wellness Days Is a “Slippery Slope”

Holthouser tries to make a distinction between self-care and wellness that demonstrates the convoluted ambiguity of both words. Rosenbaum tries to label wellness days as antithetical to learning, but Holthouser shrugs that off and tries to shift her well-intentioned focus to lack of evidence. She discusses how wellness interventions have made no reportable difference in burnout scores or wellness scores. Given the difficulty of defining these concepts and the administrative tendency to counter the scores with interventions that are more obligatory surrogates (pizza parties, wellness modules) to avoid having to make systemic change, I am skeptical that these are good measures of success.


She worries that subsequent students will take wellness days for granted and make new demands the following year, calling this a "continual erosion" of expectations for life in residency, including a sour discussion of students questioning the merit of overnight calls in medical school, the idea being that it is done to prepare them for residency overnight call. In fact, Holthouser recalls a difficult overnight call where she expressed her frustration at, you know, being on call as a student, and getting called out on her bad attitude, which likely shaped her philosophy. The unfortunate reality is that for students, there is a limit to how effective learning can be, especially at night when patient care can be more chaotic and teaching is limited aside from making minute-by-minute decisions and placing orders, which students are not doing. When students are in the midst of studying for exams and figuring out their futures, overnight call is of limited benefit. I'm not saying students shouldn't do occasional voluntary call (I delivered a baby for the first time on an overnight shift as a student), but requiring them or even grading based on them is not as beneficial as was once thought.


Holthouser asks, "How are you going to balance your wake-sleep cycle or your need to go to doctor's appointments or things like that once you're an attending?"

Listen, I do not have children, but when it comes to my job, I have WAY more time now to manage my life and my wake-sleep cycle as an attending and it would have been nice to have better practice at that with a training schedule more reflective of the time commitments.


Students Just Want to Pass the Exam Instead of Actually Learning Real Medicine

Holthouser states "That pure love of learning has been lost, and now it’s just, 'What’s the minimum that I have to do to meet some kind of external criteria so that I can match into whatever my chosen field is?'”

I do partially agree with her point about students focusing more on exams, but…they have to. With licensing exam scores rising with each year, medical schools increasing in capacity with no corresponding expansion of residency spots, the competition of the residency and fellowship Match (how American medical trainees get to the next phase of training and their jobs) gets harder and harder every year, and the stress takes a severe toll on trainees. I was discussing this interview with a friend who is also a medical educator and she brought up the better question: We need to find a better way to reconcile what learners want and need and what minimal education standards are. We also need to take down the barriers to medical training, advancement, and employment.


Burnout Doesn’t Have to be a Problem If You Just Love Your Job Enough

She discusses how she doesn't worry about burnout in HER chosen field because she loves her job (now that he has left medical education for full-time clinical duty) and that she struggles more with days off and what to do with herself. This is part of why she feels like these wellness request from students and residents are "Cognitive behavioral therapy for a broken leg" and man...that kind of dismissal is frustrating. Holthouser expresses a frustration that "we’re offering a lot of wellness programming, we’re putting a lot of financial and people resources into it, and students aren’t coming." Again, this misses the point that wellness and self-care looks different for different people. Not everyone finds complete fulfillment in their workday.


Holthouser and Rosenbaum commiserate over a persecution complex that comes with this brand of hot take. Holthouser refers to it as parenting again, having the "tough conversation" and "lovingly declining" to make changes based on learners' real wellness requests. I know of other medical educators who fear or have received threatening evaluations and lawsuits. The thought is scary, and it sucks that it does drive people away from medical education. She views it similarly to when patients who we're treating with genuine care then insult or assault us, or when a teenage "kid does something terrible" (Dr. H, you must stop labeling learners as children).


Systemic Change Required in Medical School? Nah. It’s Probably Social Media

Rosenbaum wonder if social media creates "a perception of grievance that is more ubiquitous than it might be than in days before we had social media and some of these things could just be kept to one school."

I suppose it is nice that we can always use social media as a scapegoat instead of admitting there might be universal, systemic problems with medical education.


To give credit where credit is due, Holthouser realized at some point that her approach was not being "received in the spirit that [she] was giving it" and left medical education. I believe she is genuine in her intent and her caring for students. I will not accuse her of not caring about trainee mental health (though I am not impressed by her making light of the value of rest ("you can't nap at work")) or suicide rates, but I am once again frustrated because it seems like the issues are more systemic if they're being so universally noted, and it is not increasing because students are talking or posting about it more.


************


The recurring frustration in this conversation is the issue of resisting systemic change in favor of surrogate measures or blaming students for not wanting to learn. I do agree that medical education can be frustrating at times, but evolving with the times does not mean sacrificing educational rigor. As we look back on trainee depression and other mental illness and suicide rates that have only become worse with time, we must acknowledge that change is necessary. Those of us out of training are the ones who can make that change, but we can only do that by listening to those IN training and their needs. My friend asked the right question at this juncture - how do we teach learners to give actionable feedback? And how do we get ourselves and our colleagues to a receptive place for that feedback?

I don’t have any easy answers, but I think that is where we can start.


REFERENCES:

Rosenbaum, Lisa. "Tough Love - NOS Episode 2.3." Not Otherwise Specified. New England Journal of Medicine 2024; 390:e16. DOI: 10.1056/NEJMp2400690 <www.nejm.org/doi/full/10.1056/NEJMp2400690>


Carmody, Bryan. "A Peek Inside the USMLE Sausage Factory: Setting the Step 1 Minimum Passing Score." The Sheriff Of Sodium. Posted January 20, 2019. Accessed 2/21/2024. <https://thesheriffofsodium.com/2019/01/20/a-peek-inside-the-usmle-sausage-factory-setting-the-step-1-minimum-passing-score/>


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Keith S.
Keith S.
25 févr.

Loved every word of this. Absolutely.

J'aime
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