April 28th, 2014
Cynicism in Medicine
Akhil Narang, M.D.
“Are you more or less cynical than when you started residency?” This was the question my Program Director asked our senior internal medicine residents at a recent dinner with Dr. Bob Wachter. If you aren’t familiar with Dr. Wachter, he is widely acclaimed as the “Father of Hospital Medicine” and a renowned champion of patient safety and quality. His blog, Wachter’s World, is chock full of insightful commentary on the American healthcare system, written with levitating optimism. In a time where criticism of doctors and hospitals (coupled with pessimism reflecting the country’s healthcare system) is trendy, Dr. Wachter’s breath of fresh air is welcoming. It got my Program Director thinking about cynicism in medicine and inspired this post.
The 30-odd residents, months shy of graduating, got an opportunity to answer whether they viewed themselves as more or less cynical than at the start of their residency training. Many of responses reflected increased cynicism toward “the healthcare system.” When pressed to explain further, many answers stemmed from the frustration they feel when taking care of patients: difficulty in establishing primary care follow-up for the uninsured, inability to get antibiotics covered by insurance, administrative red tape of setting up home oxygen therapy, and even the cumbersome process of obtaining outside hospital records. It was refreshing, however, to hear residents qualify their cynicism. More often than not, residents did not single out cynicism toward patients as much as they did toward the system. If we are to continue producing generations of passionate and dedicated physicians who don’t burn out, we need to start addressing ways to deal with cynicism.
Short of nationwide reform, hospitals and residency programs can play a part in helping to shape (arguably) the most pliable time in a young physician’s career. While it’s certainly character building to be able to successfully navigate filling out nursing home transfer forms, finding a means to get a patient’s INR checked, making follow-up appointments, and calling insurance companies to plead for antibiotic approval, this type of work should not dominate the daily cycle of residency. There is little doubt that “scut work” helps us better understand the bureaucracy and red tape associated with our healthcare system, but it also unequivocally takes away from a plethora of formal educational opportunities and it contributes to violations of strict duty-hour regulations.
In speaking to my colleagues around the county, I have found that hospitals and residency programs provide variable support to their housestaff: some of the best programs offer dedicated resident assistants (typically PAs) and streamlined workflows for discharging patients (multidisciplinary rounds, discharge planners to schedule appointments). Residents who were the least cynical in my unscientific polling were those who had the most resources at their disposal. I wonder if, down the line, the less cynical residents become less cynical fellows and subsequently less cynical attendings. I wonder if these physicians experience less burn out than their colleagues whose training programs do not equip them to navigate the healthcare maze.
Recognizing that all hospitals and programs are not created equal and that perks such as PAs or discharge coordinators are luxuries that many hospitals aren’t in a position to provide, addressing the larger issue of cynicism in medicine is important. A certain degree of cynicism is healthy but when cynicism borders on indifference or complacency, we’re in trouble. To effectively curtail cynicism directed at the “system,” hospital leadership needs to engage their residents. For many hospitals, residents provide the greatest amount of hands-on patient care. Residents are often the first and last providers that patients encounter during hospitalizations. Every hospital recognizes the importance of quality improvement and creating lean workflows; resident input and feedback should be solicited at every step of the way. Concerted efforts to address issues that plague residents (whether it be better social work support or a lack of computers) should be taken seriously.
Residents need to feel empowered by their programs and hospitals to make changes. Whether those changes are major or minor, a collaborative effort between housestaff and hospitals will inevitably be well received. Unilateral decision-making (especially if controversial) can lead to significant resentment and to worsening cynicism. I have no delusions that once residents and fellows finishing their training, challenges in their practice environments (academics, private practice, or industry) certainly can augment cynicism. Nonetheless, if the formative years of one’s training are optimized, scores of physicians might enter their post-training careers with a less cynical mindset.
So now I ask you to reflect on your experiences. Are you more or less cynical than when you started your residency training? If you’re more cynical, why and how much of this was a result of modifiable factors in your training program?
8 Responses to “Cynicism in Medicine”
2021-2022 Chief Resident Panel
Abdullah Al-abcha, MD
Mikita Arora, MD
Madiha Khan, DO
Khalid A. Shalaby, MBBCh
Brandon Temte, DO
Resident chiefs in hospital, internal, and family medicine
Learn more about Insights on Residency Training.
NEJM Journal Watch – Recent General Medicine Articles- How Often Does RSV Cause Outpatient COPD Exacerbations?
- Simultaneous vs. Sequential Administration of COVID-19 and Influenza Vaccines
- When to Start Anticoagulation After Ischemic Stroke in Patients with Atrial Fibrillation
- Aortic-Valve Replacement vs. Clinical Surveillance for Asymptomatic Severe Aortic Stenosis
- Do SGLT-2 Inhibitors Lower Risk for Recurrent Nephrolithiasis?
It’s especially pertinent that the word cynicism is chosen rather than discontent, negativity or criticism. It rightly implies a concern by the residents about self interest in human nature (see dictionary definitions.) This leads me to want to broaden the observations of the residents to consider the root causes: in my view, profit motive in private insurance and for-profit hospital systems, particularly. Can we ask the same question of residents in countries with somewhat successful single payer systems with their implied global coordination of services and workflow?
I think a number of us have become concerned by the ‘moving the goal posts’; first we were told to get those HBA1c down in everyone, then we were told to let the more frail older folks run a little higher; first we were told to use dronedarone in paroxismal afib, then we were told not to; in the early 2000’s we were told that pain was the 5th vital sign and that responsible pain management did not overlap substantially with narcotic abuse, now we are told that wide availability of narcotics in the community is fueling the drug crisis.
I think guidelines can be very useful and very helpful to primary care clinicians in the trenches, but I think over emphesis on, and reward for, following the guidelines is short sighted and potentially dangerous; and can increase cynicism once the occassional flaws the guidelines are realized.
Monetary incentive to follow a guideline which is subsequently found to be flawed undermines the potential benefit of future guidelines.
Fool. Workload is up and reumbursment is down. Paperwork increases daily, while autonomy drops. Respect has vanished into the empowerment of “ancillary workers” and “physician extenders” for who’s errors we are held responsible anyway. The 15 minute appointment has become standard, which really means 7 minutes actually talking to the patient, when corrected for the typing and paperwork time, and even the least skilled among us realize it is unlikely the patient gets good care with this time constraint. And if one were to take more time, it is unlikely one’s contract is renewed. And the government, and insurance companies and damn-fool CEOs, with no medical training, who would vomit and run from the room if faced with a critically ill patient presume to dictate the terms of our practice, while conspiring to screw our patients out of decent medical care, and expecting us to valiate their ill informed judgement.
And you question what can be done to make residents less cynical?
What do you expect them to do, learn to be better at self delusion, so they can “get with the system” and thereby feel better about screwing the patients? By providing false hope the real world of medicine has more autonomy and less paperwork?
It seems to me your trainees get the idea that their mission is to provide the best care possible in spite of the system. So, rather than creating some fairy tale setting for training, teach them Machivelli. You need build on thier well placed cynicism. The reidents need learn to dissemble when required, and speak smoothly to the powers while doing whatever is necessary to provide patient care up to the high standard they know is right. Otherwise, it will just be another case of another doctor walking away disillusioned, muttering something about the difficulty of believing six impossible things before breakfast…
I am less cynical than immediately after residency. First of all I was extremely burnt out at that time, which was universal among my cohort. Second, I now have the skills and influence to help make improvements in care delivery. Being able to participate in incremental local change within my health system is gratifying. I confess to being more cynical about the political process in our country, however.
After 15 years in practice I have grown more cynic. I suspected that the creation of medication was based on the interests of the pharmaceutical coporporations, now I know it is so, as evidenced by the absence of new effective antibiotics and by the proliferation of statins. I now know that guidelines are sometimes based not on evidence but on dubious science that benefits big pharma (again). Publication bias is also a painfull reality.
It is a tough world out here. Not because of the patients but because of the economnical interests that have been placed above the population interests.
It is a very ignorant mistake to place blame on “physician extenders” or Physician Assistants. We are not “low-level practitioners” as spoken by Dr. Pietruskzka, with one year education after RN degree. That is an ignorant and false statement. Make no mistake, PA’s are not physicians, and they are not pretending to be. Most Physician Assistant Programs in the United States required a Bachelor’s degree and 2-3 years of graduate training. PA’s are board certified and state licensed. While you may not be pleased that they can provide medical care at your side, it is not necessary to insult the “level” of the profession. With your cynicism I’m sure it would be most difficult to make the most out of many professional relationships that would enhance your experience in the medical profession. Interprofessionalism and teamwork are essential to providing well-rounded quality care to patients, regardless of the insurance red tape and reimbursement failings. It is time to respect all members of the hard working medical team.
It is difficult to not be cynical when PA’s and NP’s are taking over the practice of medicine. Why are we training medical students to practice medicine when all you need is an RN degree and one year of training. Do they really expect to save money by employing low level practitioners?. Perhaps they will save money by allowing the ill to die sooner. Where the leaders and university researchers who encouraged this return to low level medical care been? Perhaps, cloistered in the ivory tower, writing research papers, and. writing grant proposals If we have a physician shortage now, wait until potential future physicians find out that they can do the same work and get paid about the same with five years of training after high school.On a more positive note, I am mentoring an IMG who is looking for a first year Internal medicine residency or externship. Please respond. Thanks, MP
Dear Dr. Narang,
Thank you for your post.
I’m a PGY4 in Emergency Medicine, up in Toronto, Canada. Although our system is slightly different than most US jurisdictions, I do see this cynicism-creep in all my colleagues (regardless of chosen specialty).
I think this stems from inherent mistrust that our attendings instill in us, and then us confirming that mistrust when, for instance, we review the H&P with the medical student. This is of course on the background of a heavy admin/skut burden while trying to perform patient-directed clinical duties, and juggle the health-care team demands.
According to our surgeon colleagues restricting Resident Duty hours is not the solution to improving “wellness” (as much as that relates to cynism): http://www.ncbi.nlm.nih.gov/pubmed/24662409. But, I really do believe that the key to live & work uncynically is to have fun with what we do and not to take ourselves too seriously…. that’s why I chose Pediatric EM as my subspecialty – this approach is both taught and encouraged!
Max