Friday, October 12, 2007

Physicians' "Learned Helplessness"

An important article on Medscape General Medicine, by a lawyer, of all people, suggested how physicians have developed "learned helplessness." [Bond C. The training of the "helpless" physician. Medscape General Medicine 2007; 9(3):47.] Bond had two causative hypothesis on how this happened.

First, medical schools and post-graduate training programs do not teach physicians how to cope with the current health care environment.

Medical training programs do not provide young physicians basic information about doctors' options in the workforce -- for example, the pros and cons of private practice vs employment -- nor is there any effort to explain to them the larger economic forces at work in healthcare in the United States, so physicians do not understand the competitive forces that are shaping today's radically changing economic climate.

Doctors, having received no training in adapting to the current market conditions that are occurring rapidly around them, are ill-equipped to function in this radically changed economic -- and ethical -- landscape.

Beyond the basics of medical economics, young physicians are generally not introduced to the regulatory and political environment in which they will have to practice.

More importantly,

Medical training is inculcating a culture among physicians that may be deepening their woes and contributing to the decline of the profession.

Helplessness can be trained into individuals when, regardless of repeated best efforts that should be rewarded, no reward is forthcoming; as a result, the individual eventually learns to give up and sinks into a lonely feeling of futility and malaise. It would appear that collectively the medical profession has mastered this art and is suffering the symptoms en masse.

Unfortunately, medical training is helping to create the foundation for the profession's helplessness. Regardless of the new limitations on work hours, conditions in many training programs remain reminiscent of medieval, monastic, ascetic orders. Self-deprivation -- especially sleep deprivation -- continues to be viewed as a necessary virtue, especially during subspecialty training. Learning is still most often imposed on the basis of the model of strict authoritarian discipline, with a high degree of emphasis on shame and fear of failing. Good patient care is so expected of trainees that it is rarely rewarded. Residents' pay is usually set at bare subsistence levels or below, so there is no financial reward for the hard work of medical training, and indeed most medical graduates emerge with huge school loan debts.

Psychologically, young physicians often expect residency and fellowship to be the crowning experience of their long educational path. Since they were 5 years old, these young people were told that they were the brightest and the best, a message that was socially reinforced as they successfully progressed through school, college, and medical school. Everything about their experience reinforced their belief in the Puritan work ethic: If you work hard and do well, you will be rewarded -- until they reach residency, a point at which rewards are so few and far between that they begin to believe that if they work hard and do well they will be resented.

Young physicians become so well trained in deferring gratification that many give up on ever getting any meaningful rewards for their sacrifices. With their resilience worn away, many just give up the fight. A dispirited acceptance of one's individual fate seems to be the dominant mood of physicians nowadays rather than a motivated mobilization toward a better lot for the individual practitioner and the profession as a whole. Most doctors focus so hard on trying to provide good patient care -- ie, taking care of others -- that they forget, or have no energy, to take care of themselves. Thus, when some doctors propose positive collective action, they are usually quickly quieted by a few naysayers whose negativity taps into the helplessness learned so well during medical training. The progress of the profession is being effectively paralyzed by its own failure to teach leadership and the skills of self-survival.

Strong stuff, that.

There are, of course, two obvious solutions.

The first is to teach medical students and house-staff about the realities of the professional world they will inhabit. In my humble opinion, this would include teaching about evidence-based medicine and technology assessment so that they have some framework to evaluate the maelstrom of marketing, propaganda, disinformation, and intimidation and coercion that they will encounter. This would certainly also include discussion of health care ethics, i.e., the issues that we discuss on Health Care Renewal. This sort of teaching need not focus too much on how to recognize conflicts of interest and corruption (which is pretty obvious), but should focus on helping the learners resist these "dark arts." (This should be distinguished from traditional biomedical ethics courses, which mainly focus on analyzing difficult clinical decisions, important, but not the same thing.)

Note that efforts to teach even the rudiments of evidence-based medicine have not gone very far. We can also surely expect a lot of resistance to teaching about the sorts of ethical issues that appear on Health Care Renewal. After all, that might make certain medical school, academic medical center, and university leaders, starting with those who also sit on the boards of directors of public for-profit health care corporations, uncomfortable. In fact, I know of no US medical school that requires any education in any such issues. Further, Bonds noted,

One attempt to institute a seminar-style course in 'real-world' healthcare economics at a major State University School of Medicine was met with a refusal to fund even the modest travel stipends for the national experts lined up to teach the course.

The second solution is to change the culture of medical education itself. We need to lessen the crushing sleep deprivation and the long work hours which still occur when the work-week is limited to "only" 80 hours. We need to make teaching more collegial and less authoritarian. That may require actually paying medical school faculty to teach in clinical settings. (In many schools, the first priority is on faculty raising external funds for the school through research and patient care.) This may also require banning the conflicts of interest that let faculty work as much for pharma/ biotech/ device companies as they do for the medical school, e.g., as noted here. None of that will be easy either, especially because such changes would obviously disrupt some economic relationships that are very lucrative to certain people.

Nonetheless, physicians are going to have to unlearn their helplessness if they expect to do anything about the mess that is health care today. They certainly ought to feel obliged not to let the next generation of physicians be taught to be helpless as well.


InformaticsMD said...
This comment has been removed by the author.
InformaticsMD said...

Quite a provocative article.

Thus, when some doctors propose positive collective action, they are usually quickly quieted by a few naysayers whose negativity taps into the helplessness learned so well during medical training.

This article may explain why clinicians take a rather passive approach to challenging the domination of clinical information technology by non-clinicians, and to challenging the failures of this technology to meet clinical needs and realities.

Anonymous said...

Docs become helpless or the victim becomes the abuser. Both abysmal outcomes.

Anonymous said...

the best is always expected, consequently compliments or positive reinforcement is usually omitted from medical training, and we knew from the beginning to accept this, delayed gratification began in college and persisted for years. However if you like caring for sick people it's all worth it, if not you"ll be miserable. Many people go into medicine to fix what's wrong with them; not to care for patients, and they don't know the difference...

Anonymous said...

love it