Attempting Perfection in a Volume Model
She was a physician starting a new fellowship at a Manhattan teaching hospital. She jumped to her death from the top of a 33-story building that provided housing for physicians and physicians in training. The building is less than a block from the hospital where she worked. She was not the first to jump off the roof of this building. The response to her suicide is told in the blog of a champion for addressing the issue of physician suicide, Dr. Pamela Wible. Dr. Wible also gave a eulogy for this physician – a transcript is published on her website.
Within less than an hour, as her lifeless body lay under a tarp at the entrance of the building, Dr. Wible received numerous emails from people concerned about the epidemic of physician suicide and the loss of another one of their colleagues. One email was from the wife of a resident physician. She lamented, “Words can never describe how it feels to see a dead body outside your window. A beautiful lifeless body of a beautiful doctor… What am I supposed to tell my daughter when she asks, ‘Mommy what’s that?’”.
A physician wrote, “I have a career ahead of me, which I’m too scared to speak out against. I come home again to another suicide. Another doctor dead… Conditions are deplorable for doctors and you should investigate… They will likely say she was troubled, but why was she troubled!?? Because she wasn’t efficient enough? Sad and overworked? Our hospital will make it about her. Like the girl that died last year, she was too sad.”
Dr. Wible adds to the article, “Doctors were working in the hospital right next to this building and could see there was a woman preparing to jump. They witnessed her fall. They knew she could be one of their friends (since the building houses primarily doctors). Yet these doctors had to continue to care for patients amid their tears and screams at the window. Many have flashbacks to colleagues that jumped from the same building in previous years. ‘It is always the same thing,’ says one resident. ‘The hospital sends the usual ‘we’ve had a tragic death’ email. They tell us to meditate, sleep and hydrate. Then it happens again.’”
One of the problems with our healthcare culture is that from the first day of medical school we are inducted into a culture of competition and perfectionism. We’re graded and ranked throughout our four years. Even deciding what type of doctor we would like to be is determined, in large part, by the score on standardized tests during the first few years of medical school, called the STEP exams.
These scores have been used to determine whether a medical student receives an interview for a residency position. In general, the more competitive residency positions, like orthopedic surgery, radiology, and dermatology, require the highest scores. A low score on the STEP exams will severely limit a medical student’s options for what type of doctor they will have the opportunity to train to be.
I was confronted with this competitive culture almost immediately when I started medical school in 1985. After my first major exam in Anatomy class, there were complaints about certain questions and the competitive nature in medical school became obvious to me – it wasn’t pretty. I was naive and idealistic entering medical school thinking it would be four years of learning how to be a good doctor. I didn’t realize the healthcare education system, and healthcare in general (with its volume model), had been in place with no significant structural improvement for nearly a century.
After that test, I took a job as a doorman at a local bar. I made $5 an hour, plus all I could drink on or off the clock. It was my first six-figure salary. I only went to class if there was an exam. I passed every class (thank goodness for note service) and graduated on time, but my class rank was not high. I didn’t care about class rank; I just wanted to be a good doctor and help people. I learned much more about being a good doctor from working as a doorman at that bar (a much more collaborative environment) than I ever would have if I went to class.
As a doorman, I learned how to deal with all types of people in all kinds of mental states: drunk, depressed, angry, etc., and I learned how to do it with dialogue and compassion, not with violence. I once had to “escort” a 300-lb former Alabama national championship football player out of the bar because he was unintentionally knocking people over on the dance floor. That was not fun, but the ability to talk to people in all sorts of mental states and give them bad news and explain exactly why you are doing the things you’re doing is very helpful in medicine and surgery. With the help of a co-manager, we were able to talk the ex-football player outside of the bar, where he promptly went to sleep on the hood of someone’s car.
Unfortunately, I was not able to stay isolated from the competition mindset and volume model. Through my early career, I was conditioned into that culture and I’ve described the harm that resulted from my experience.
With a culture of competition and perfectionism, it’s almost inevitable that a medical student will suffer from anxiety and a feeling that they are not living up to expectations. As they become resident physicians in training and then young doctors, they will make mistakes. We all make mistakes. No matter how hard we try, we can’t train the humanness out of our bodies. When those mistakes are criticized, by us and others, this can lead to guilt and shame.
This is especially harmful when an error is linked to a patient complication or death. Without a culture and support system to address the healing necessary to recover from an unintentional error, the guilt and shame can fester and lead to denial, cognitive dissonance, apathy, learned helplessness, depression, burnout, and even the potential for suicide. Our medical education and healthcare systems do a disservice to physicians – when perfection is the expectation, error is blamed on the individual and the volume model persists.
In a 2018 American College of Surgeons (ACS) Governors Survey with a 91% response rate, almost 30% of the responders knew a surgical colleague who had died by suicide and over 70% had witnessed a colleague experience burnout. In a prior ACS survey of nearly 8,000 U.S. surgeons, it was documented that more than 30% of surgeons screened positive for depression and more than 40% had symptoms of burnout. The work-related factors that correlated with depression and burnout were the number of nights on call per week, the hours worked per week, and if a surgeon’s compensation was entirely based on billing – the Volume Model.
In an article in 2019, Dr. Elisabeth Poorman identifies depression and suicide as an occupational hazard for physicians. She writes, “Dysfunctional work environments, unrealistic productivity requirements, and the moral injury of systemic inequality in healthcare drive persistently elevated rates of depression and suicide throughout our careers.”
And, in her latest book, Dr. Wible argues that the current environment and structure in healthcare raises to the level of a human rights violation, and she gives many practical tools to empower victims to prevail against institutional abuse.
These systemic issues resulting in harm to patients and to the people caring for them are being recognized. Within the past year it was announced that the STEP exams will be pass/fail, decreasing the stress and anxiety for many medical students. Admittedly, this is a relatively simple solution for a complex problem, so there will likely be unintended consequences, but at least attempts are being made.
As for the systemic harm in our healthcare institutions, I don’t believe it’s intentional. I don’t think there are groups of healthcare leaders that have intentionally designed and maintained a system that results in such harm and abuse. I just think they don’t know what to do about it. Or it could be that the kind of structural changes that are necessary to make true transformational change are just too uncomfortable for them to consider.
If you’re a medical student or physician feeling overwhelmed or hopeless, and especially if you are considering self-harm, please reach out for help. It’s not your fault. You are not weak. However, when reaching out for help use appropriate caution; use only confidential resources. Unfortunately, there are still many potential repercussions for doing the right thing in healthcare. The system still often requires physicians to be perfect, despite reality. There is no amount of training or unrealistic demands that will beat the humanness out of us. We are not machines; we just want to do what we went into healthcare for: help people.
Sometimes that means helping ourselves.