For Healthy Patients, Train Healthy Doctors

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Medicine is suffering from a burnout epidemic, and this is bad news for patients. Burnt-out doctors make more medical errors, their patients develop more hospital-acquired infections, and they get sued more often for malpractice. Yet no one has come up with a reliable way to prevent it.

That's because we're not starting early enough. The key to preventing burnout is to change the culture of medical training to protect medical students while preserving rigor. The good news is that we already know what works.

As the vice president and executive dean of West Virginia University Health Sciences, and before that in senior leadership positions at the Ohio State University College of Medicine, I've seen up close how our training system jeopardizes our medical students. Training more often resembles a Marine boot camp than the challenging but supportive training environment that aspiring healthcare professionals need. But boot camp ends in 13 weeks. Medical students endure grinding pressure for years.

I routinely see first-year medical students study 8 to 12 hours a day, seven days a week to prepare for their boards, which are the extensive standardized exams they must pass to earn a medical license and a competitive residency. Because of the overwhelming study schedule, many socialize only when they study together, fail to exercise, or complain that they have no life and no time for non-school friends and family. Some lose their sense of self-worth if they fail a test. Some spontaneously weep. Most have at least one episode of deep despair.

Some who might otherwise be fine doctors don't make it through the training. Rates of depression in medical students are twice the national average for people in their age group; suicide rates are three times higher. In May, a fourth-year student at NYU School of Medicine was found dead after committing suicide in her room. In 2016, a student at the Icahn School of Medicine at Mount Sinai in New York jumped out of an eight-story window.

Some degree of stress comes with the territory. Compassionate people drawn to caregiving may be more susceptible to depression. Medical students must grasp a huge amount of science early on, from anatomy to pathology, biochemistry to pharmacology, along with multidisciplinary fields like aging, nutrition, epidemiology, and medical ethics. Later, trainees are exposed regularly to sick and dying patients, which can take its toll.

A lot of the stress, however, could be avoided.

Medical training is often unnecessarily hypercompetitive. Some medical students face mistreatment by supervisors. A newly minted physician leaves school with overwhelming debt, now often $200,000 or more.

As medicine becomes profit-driven and transactional, aspects of that culture are penetrating training. Medical students are often trained to get up to speed to see a certain number of patients or read a certain number of radiographs per day, even if they spend too little time with their patients.

Those who do get depressed often fail to seek help. Traditionally in medicine, "toughing it out" is admired and admitting depression is seen as a weakness.

There's much that those of us who train doctors can do to stop wounding our future healers.

Wellness programs for students and staff can help, including mindfulness training, yoga, exercise programs, dietitians, and outdoor respite space. Social events that help students connect outside their study circles and support each other can help, too. However, medical educators also need to step up.

Fortunately, some are.

New York University moved in August to establish free tuition for all medical students to ease students' financial pressures, though students will still have to pay for room, board, and living expenses.

St. Louis University altered its medical training curriculum. Among other changes, it streamlined its course content and switched to a pass/fail grading system. Depression and anxiety rates in first-year medical students dropped dramatically, and scores on Step 1 board exams improved.

At West Virginia University (WVU), we're reforming our application process to look holistically at the applicant, rather than just at their test scores and grades. We're also moving toward curriculum reform. To filter nonessential information and save students time, we plan to shorten and focus lectures to directly cover materials emphasized on the board exams. To ease the overly competitive atmosphere, we're encouraging students to team up with each other and with other health-care specialists at WVU Health Sciences Center. We've developed a simulation environment that allows ultrasound trainees to practice procedures and patient exams and read scans rapidly to diagnose patients—all tasks they'll need to do on the job. To reduce the debt burden, we've begun reducing the training time for select students from four years to three-and-a-half. To reduce stress overall, we're adding an experienced psychiatrist and behavioral health team to work directly with our medical students to build resilience and treat mental health problems. We're also teaching students life skills and effective patient communication skills. Finally, we are urging our faculty to model these skills.

Incentives also need to change at the national level.

Medical students are seen as successful if they get high grades, pass boards, match into a good residency program, and attain a professional license. Institutions are deemed successful if they have competitive admissions, rank highly, and place their students regularly into residency programs.

We've lined up incentives for students to become great test takers, not great physicians.

What we need are new incentives. We need to train doctors to work in teams to deliver quality, individualized, evidence-based care in a reasonable time frame. That includes spending sufficient time with patients to diagnose and treat them effectively, as well as caring for them not as sources of revenue, but as patients and as people.

This would be a giant step toward the system many of us really want—one with healthy patients, healthy providers and healthy communities.

Clay Marsh, MD, is vice president and executive dean of West Virginia University Health Sciences Center.

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