Medical Care


Medical Education

Some Topics

Adversities Facing Students, Residents and Physicians

According to Watson:" In the popular imagination, medical residency is less a training program than a rite of passage. Those who successfully navigate this process are crowned physicians, with the ability to make life-and-death decisions. Those who don't succumb to the necessary culling process that ensures optimal patient care. The system, the theory goes, is a merciless but impartial judge. Recently, stories have come to light that challenge this egalitarian notion. Some residents claim that they have been forced out of programs, not because of any deficiencies in their abilities or knowledge base, but rather because they experienced serious physical illnesses that required accommodation. Collectively, their stories paint a picture of an educational system that at best has serious flaws, and at worst is punitive and discriminatory."

The biggest hurdle to much needed reform is the difficulty and reluctance to overcoming a culture in which higher learning can take a back seat to conformity. According to Pamela Wible, MD, founder of the Ideal Medical Care Movement and author of the book Physician Suicide Letters—Answered, many residency programs thrive on a culture of fear, which in turn creates conditions in which mistreatment goes unpunished. "When a colleague is being publicly mistreated, the other six residents are often witnessing it," she said. "This creates fear. You don't want to be the next one to be mistreated." Self-preservation can lead to complicity with these human-rights violations, Dr Wible explains. For those seeking to reform a century-old system, discussion of fairness will accomplish little. The system, they claim, is entrenched; those who have successfully gotten through it themselves are not inclined to change it The opinion of many practicing physicians is, "we had to do it, so you have to do it too". Furthermore, pressure on trainees from physicians in charge of residency programs can create a culture that frays what should be a natural bond among residents who are going through something together. Those being trained in the care of patients at their most vulnerable might be conditioned against empathy toward their peers.

A prominent issue for residents is the demands on their time and sanity imposed by hospital administrations.  Attempts to institute 16-hour-a-day limits have been met with stark resistance from the medical community and academic hospitals. In addition to entrenched cultural issues, there can be a monetary incentive to maximize resident labor. Critics say this combination results in famously demanding work weeks, which can be 120 hours and can, in turn, leave residents with medical conditions open to disapproval. "Whether it's because they're still in training or because they really do need this almost slave-like production, there's an intolerance to residents having any sort of lack of efficiency or production. If they can't keep up, then they stand out from their peers as being unwilling to carry the load, but the inhumane system is not addressed.

Sexual Harassment

Among the many experiences that make the medical workplace environment hostile to students and medical personnel is sexual harassment. Women or more vulnerable than men. Seventy one percent of female physicians and 25% of male physicians report having been sexually harassed in training or medical practice in a recent poll. Sexual harassment takes many forms: sexist comments or behavior; unwanted sexual advances, which may be coercive; sexual threats; and bribery to engage in sexual behavior. Perpetrators can be patients as well as fellow physicians. Medical students encounter sexual harassment as often ;as physicians. 54% of medical students — including 72% of women and 19% of men — said they had experienced a wayward hand or remark. One in four of this group said these episodes affected their career advancement. Women in medical practice have more ability to handle sexual harassment than medical students and residents, who may not be able to find a new school or training program to continue their education. The problem of sexual harassment persists despite years of attempting to combat it through institutional policies and education. (Robert Lowes. Most Female Physicians Report Sexual Harassment at Job. Medscape August 24, 2016 )

An Impossible Job?

The medical Literature in the USA has focused on medical "burnout" and expressed concerns about physician leaving medicine prematurely. Well- concealed causes of the problems physicians face is the nature of medical practice itself- uncertainties, information overload, overbearing administrations, patients expectation and the nature of disease, an ever changing realm of complex, poorly understood phenomena. Medical diagnosis is a difficult task that combines intellectual and intuitive skills. Well-defined entities with structural changes in tissues are the easiest to diagnose. Most medical technology addresses these needs. The specification of coronary artery disease, for example, can be precise and is a tribute to the combined effort of physicians, technicians, engineers and equipment manufacturers to fully reveal a disease process. The precision of these well-defined areas of medical concern may mislead the unwary into thinking that all areas of medicine are equally well defined or can be well defined with just a little more effort; however, most disease processes remain obscure and are genuinely difficult to characterize and understand.

Common syndromes are diagnosed on clinical grounds often with no objective evidence whatsoever. While the history of migraine headaches is distinctive and an astute clinician can make the diagnosis on history, the emergency room physician will have trouble deciding whether a patient with a migraine story is really suffering pain or simply wants a narcotic drug. The diagnosis of depression is another subjective syndrome that requires a historical understanding more than positive lab tests. The irritable bowel syndrome is also diagnosis of exclusion. The patient may suffer a great deal but tests are repeatedly negative. The list of ill-defined syndromes is long. A shift from category diagnosis to understanding the process of disease is helpful to understand the patient but is often not acceptable to agencies that pay the bills. The insistence for a disease category works against progress in understanding disease, simply because everyone wants to know what this is called and not where it came from and how to prevent it from happening.

Medical Costs

America spent an estimated $9,451 per person on healthcare ( i.e. medical care) in 2015, by far the most of any country. However, among wealthy, industrialized nations, the U.S. has the largest share of residents not getting the medical care they need due to financial costs. Among the 35 member nations of the Organization for Economic Co-operation and Development, America is the only country without universal health coverage. This inconsistent coverage and care can create large disparities in health outcomes between populations. For the first time in decades, life expectancy in the United States fell in 2015. With a life expectancy at birth of 78.8 years, the U.S. ranks 28th among OECD countries. In addition, the U.S. is expected to fall even further behind other countries in the future. By 2030, life expectancy in the U.S. is expected to be on par with the Czech Republic for men and Croatia and Mexico for women. Poor life expectancy in the U.S. is partially caused by differences in quality of and access to care, as well as a number of socioeconomic conditions that can affect health outcomes. As a result, longevity varies significantly from state to state. Hawaiians have the longest life expectancy, of 81.2 years. By contrast, the life expectancy in Mississippi is only 74.8 years, the shortest of any state.
(Steven Peters  States With the Longest (and Shortest) Life Expectancy Wall St. February 25, 2017)

 

John Watson. Do Unto Others: Treating Physician Patients. www.medscape.com. October;26,2016.


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