S7E23: Healing the Structure of Medical Training

Austen: Well, welcome back to "Bundle of Hers." Thank you for joining us today. Welcome. I'm Austen.

Today, we are going to be discussing a topic centered around the rigidity of the medical apparatus and the medical education structure, and how this very rigid and demanding structure impacts everyone within it, from medical students to residents to physicians, and ultimately, it can affect patient care.

This is a topic that I've been thinking about for a while based off of personal experiences that I've had interacting with the medical structure as a trainee.

And joining me today for this discussion, I have two incredible women. So first up, we have Dr. Jenny Wei. She completed a family medicine residency and palliative care fellowship in Texas, where she worked as an inpatient and outpatient palliative care doc. In 2014, she came on over to the University of Utah, where she's been working as a palliative care physician here.

In addition to being a kick-ass doctor, she is also a Layers of Medicine facilitator. So she is in charge of a small group leading discussions around medical ethics, and that's how we initially met. She was my Layers of Medicine facilitator for that.

So to sum it up, Dr. Wei is a powerhouse of a physician, as well as a powerhouse of an educator, and I'm so grateful that she could be one of our guests today.

In addition to Dr. Wei, we also have Sanila. Sanila is a friend of mine, a really good friend of mine from my class. So she's also a third-year med student here at the University of Utah.

And in addition to being brilliant and awesome and fun and kind, she is also one of my class's two AAMC representatives. So she gets to go to basically the governing body of medical education and kind of fight for change and be a voice for change for my medical school class.

I'm so glad that both of you could join me today. Welcome. Thanks for being here.

Sanila: Thanks, Austen, for having us. I'm really excited for this episode.

Dr. Wei: Yes, thanks for having us.

Austen: So like I said before, we're going to be exploring the rigid structure of medical education, some of the drawbacks of that, some of the impacts that it has on physicians.

And this isn't just something that I'm like, "Oh, it's hard to be a medical student," or, "It seems like it's hard to be an attending physician. That must be difficult. That must have a negative impact." This is something that's been very well documented. It's been studied just how taxing the medical structure can be.

There are tons of data from decades documenting that physicians experience high rates of burnout, high rates of depression, high rates of suicide. And so I feel like for me and Sanila, as people who are just entering this field, and for you, Dr. Wei, as someone who's worked within it for many years, this is, I feel, potentially a very meaningful conversation.

Before we kick off this discussion, I just want to start off with our disclaimer. The views and perspectives that will be shared on this show by myself, as well as by the guests, are a reflection of our own personal views and in no way reflect the institutions that we're a part of.

But at the beginning, right before second year started, mine and Sanila's class, we were informed that one of our classmates had passed away. And it was interesting to see the school's response to that news and the expectations of the school that they had for us in light of this news.

At least I can only speak from my perspective. Sanila, I would love to hear what you think as well. But I thought it was interesting that we got this email on a Thursday at like 6 p.m. that someone that we loved and someone that we knew really well had passed away.

We had Monday off, but then Tuesday came around and we hit the ground running. We were in a full day of classes. It almost felt like everything was business as usual.

Obviously, we have to continue to learn. We can't just stop learning forever. But I think the whole experience kind of left me wishing for maybe a little bit more grace during that period.

Like I said before, we got the email on a Thursday, and the very next day, I had to go to an all-day meeting for school. It was like a training that had to happen. I understand that. But we started off the meeting like 14 hours after we found out the news, and someone was just like, "Sorry about your classmate. Let's get this meeting started."

I think I was just taken aback, and I continue to kind of feel this frustration. Even though we were training to take care of other people, take care of people for the rest of our lives, it didn't really feel like we were being taken care of in the same way.

Sanila, I would love to get kind of your perspective of that time, the response to that news, that really big, heavy news, and things that you appreciated, and maybe things that you wish were a little bit different.

Sanila: Yeah, I think you summed it up pretty well. I think it felt really frustrating to hear that news. And then as you said, it was kind of just business as usual right after.

I think there's this expectation that future physicians and physicians alike have to be resilient in the sense that you have to be able to handle bad news, navigate it, take care of yourself, and then resume your daily operations as normal.

It's not a resiliency in the sense of you should be able to learn how to care for yourself enough to be able to navigate those things and feel like you still have the ability to come back and help others. So I think that's what was difficult.

What the school did well was share this news with us in a way that protected the family's privacy. I think that was the first priority that the school should have done, and they did that. I think what was hard was that there wasn't really much given after it. It almost left me wanting more.

And I don't even know what that response would have looked like from the school, because I think I have a hard time separating the people who work in admin from administration as a whole. I like to think that the people who work in admin really did care for our classmate and friend. I'm sure that it impacted them just as much as it did us, and that's always hard for us to see sometimes.

I think on administrative levels, there were probably a lot of policies that are hard to work around and navigate. And I think that's just something that I don't really know enough about to be able to speak about what I wish the school had done differently.

But I agree, I definitely felt like I wanted more of a response. And maybe Dr. Wei can also talk about what that looked like on the admin side of things.

Dr. Wei: It's interesting to hear from you guys' perspective, because our end, when this news came out, I think most of us, especially the facilitators involved with Layers, we were just in sheer shock. And many of us just replied all to the email like, "What happened?" And so I think there was this initial shock.

But certainly, I think there was a lot of struggle from the administration side to really support students while trying to respect the family's privacy. Thinking back, I don't know what could have been done necessarily to make this change, because we really . . . The student and family privacy was, first and foremost, really important. I kind of wish that perhaps some time was given off for the students to really just process this information.

And it makes me think about this expectation for us as physicians, because you guys are all training to be future grown-up adult doctor. This expectation makes me think of when you have a code, when you do CPR on a patient, and the patient still dies after you perform such heroic aggressive measures to try to change the outcome. It's common to just move on, and you're supposed to just dust yourself off and say, "You know what? You've got other patients to take care of. You've got learning you've got to do. And so this is part of the learning process."

So it makes me think of that and makes me think of why the system is perhaps set up for burnout, and we're not really taking care of ourselves and each other.

Austen: I think it helps to kind of explain some of the interactions that various students had with faculty following the news of our friend and classmate's passing.

Before we go on, I want to say Dr. Wei did such a great job at that first Layers that we had back of giving us that space. And that was something that I really appreciated. We were learning about racism in medicine, which is important, something that I feel very passionate about, and something that I think everyone should talk about and think about and kind of work through.

We got to our lesson, and I think you could tell that all of us just needed some time, and we just needed to kind of sit in our grief a little bit and also reflect on the joy and the life of our friend.

So I was so appreciative that you were able to recognize our needs and, the physician you are, meet your patients, or in this case, your students, where they were at to make sure that they were taken care of in the way that they needed to be. So I want to thank you for that.

And it makes me curious what you feel like have been good either experiences or maybe a new perspective that you've gained through your career as a physician, as far as helping you develop mechanisms to kind of overcome sometimes this feeling of overwhelming despair.

That sounds dramatic, and I don't mean to sound dramatic. But sometimes it's easy to feel like, "I am one person, I cannot do this all alone. There is so much that is out of my control, no matter how hard I work." And I think that can kind of ramp up until we feel just so overwhelmed.

And so I'd love to get your perspective of how you've been able to combat that, especially in a field where it feels like life is so delicate. The care that you provide to your patients is so needed and crucial, because they are at a place where maybe the focus of their care is no longer, "Hey, let's try to save them," but, "Let's try to make sure that they still feel supported even if, ultimately, the worst outcome comes to fruition."

Dr. Wei: I think there's a lot of expectation on us medical providers to be Superwoman, Superman, Superbeing that provides great care and does not need rest and does not need support. And that's not the case.

I feel like there's always going to be stress in your learning, in your education, in your career. I used to think when I was a student, "When I'm a resident, this will get better." And then when I was a resident, "When I'm an attending, this will get easier." And it really doesn't. It just kind of gets harder.

So when you said this . . . What did you say? "The overwhelming despair"? How did you phrase it?

Austen: A sense of overwhelming despair. Yeah.

Dr. Wei: Despair. I was like, "Oh, yes, I remember having those feelings." And how did I overcome that? I think ultimately, I guess this comes to me being the older, more senior person here giving advice is just perhaps finding a field that really speaks to you. That's number one.

I think I might have mentioned this maybe, Austen, in my small groups before. Every physician has sort of their kryptonite patient. For some patients, it's the patient that is super depressed, and really, there's no cure to their depression. You've tried a bunch of things, and things aren't getting better. And so that makes you have this ongoing overwhelming sense of despair.

For me, what I found in palliative care really helped sort of renew my perspective and helped give me hope that this is something sustainable for me as a career option. The patients I take care of are just so desperate for the conversations to be open and frank about their end-of-life options, to give them back a sense of control that they've lost throughout their journey of cancer or whatever disease that is ongoing and progressive and incurable.

And knowing that they're going to feel good. Even though we can't fix their numbers anymore, I know I can make them feel as good as possible for as long as possible.

So that's number one, finding your specialty and avoiding your kryptonite sort of specialty, so to speak.

And then the next part, I think finding a group of people that really support you at work is really important. People tend to think that palliative care probably has a lot of burnout. But if anything, we probably have the least burnout because our work tends to be supported by a team. You're not a one-person-does-all type of specialty. You kind of have social workers, chaplains, a lot of people supporting you.

But the people I work with, I consider them friends. And so finding the people that you mesh with, that you can go to work every day, and know you're supported.

I think those have been my coping mechanisms, so to speak. Finding the right specialty and finding the people that I know I can go to and rely on for support when times are hard.

Sanila: Thank you, Dr. Wei, for sharing that. Austen, I really liked what you said earlier about how Dr. Wei had created space for you and your group to process and feel. I think my Layers professor also did an incredible job of just creating space for us throughout the whole year.

And the reason I think that's important is because when I first heard the news, tying this back to our classmate, I kind of felt like my grief would be best processed by seeing the impact that it had had on other people. I wanted to feel like this loss was felt by more than just me. I couldn't do that on my own, and I came to realize that.

And in hindsight, I think it's because I feel that grief doesn't have to be public to be real. And so a lot of people feel things privately, and it's hard to see that when you're just an onlooker.

I also think that grief isn't necessarily uniform. I think a lot of people have this idea, myself included, that grief has to . . . you have to feel sad. That's just all that it looks like. But I think it can take the form of feeling frustrated or isolated, or even feeling anger.

One of our professors said something that really resonated with me when we first heard the news. And they had said that they felt angry because they felt that not only was this a loss, but that we had been robbed of potential of a classmate and friend. I think that was really pivotal for me, because it just, again, proved that grief can take the form of a lot of different things.

And when you have this idea that it looks like one thing, and so the solution is the opposite of that . . . for example, grief is sadness, so the solution is to be happy . . . I think you find yourself really limited in how you can process and navigate that. It feels like there's only one solution, when in reality, it's a lot more complex than that.

For me, I found that being able to share with people stories and experiences and feelings was really good in helping process that. And I wish that there was more time to be able to do that in our daily lives.

And I guess that's the point of this conversation, is that it's hard to do that, because everyone is so busy. It's always go, go, go all the time. But those are my two cents on that.

Austen: Like everyone has mentioned so far, time is typically not something that we have a lot of in this field, unfortunately. But that's why I think discussions like these are important, because even though we might be severely constrained when it comes to time that we have, I think that's when we can kind of talk about solutions and how to operate within the constraints that we find ourselves.

So I'd love to get both of your perspectives on how you think that we can make improvements, whether they be big or small, within the medical system or structure that will allow us to feel more human at the end of the day. I think that's my main concern.

I look at the reaction to our friend's passing, and I'm like, "If I only got one day, and I'm a med student with minimal responsibility, what's that going to look like when I have patients passing away as an attending?" or, "What's that going to look like if I have family members passing away when I'm in residency or wherever I end up?"

And so I would love to get you guys' perspectives and kind of insight on maybe changes that can be made or changes that have been made that you really appreciate, that you feel like allow you to feel human at the end of the day, allow you to experience humanity, in addition to healing humanity.

Dr. Wei: Well, this is a tough one. It goes back to finding the right specialty. And then for me personally, you just sort of develop ways to become more efficient with experience. That's number one.

But my hope is that as we look at some of the flaws in our healthcare system, there are positive changes made to these outpatient visits. Twenty minutes, addressing 30 medical problems, that's sometimes . . . I'm not over-exaggerating. Sometimes that's what you're expected to do as a PCP, right? And so I'm hoping that those changes come along.

I have seen some changes over time, but certainly, we could always improve. That is my answer.

So really a tough question to answer. I can only say from my perspective, is just learning ways to be more efficient over time.

I think you will always feel time constraints, because I think outside of medicine, you have your personal life, you have . . . I have a kid, I have a zoo of animals, and all these things I've got to tend to outside of work. And so you're always going to feel like there's a time constraint. So I think it's important to start developing some habits to just really have reminders throughout the day and just slow down for yourself.

And the other thing that I also try to do really is I try not to work through lunch. My lunch may be 15 minutes, but those 15 minutes, I either read or do something. I don't chart. I do something just unrelated to work and it's just for me. Or sometimes I just grab a colleague and the two of us sit down and eat face to face and talk about how things are going in our lives.

So I think you have to kind of find some ways to make it not feel so overwhelming. It'd be really hard to say we're going to be in a field and in a world eventually where time constraint is never going to be an issue.

Austen: I think that makes sense. And I think that's a realist view of what's going on. I think in the US, we have an overwhelming amount of patients that need care, and not very many physicians. And so the physicians who are here are running around, their days are full. Their patient load is full. And they genuinely want to provide good care to each of their patients.

And so I think it makes sense to think about those ways that you can hold space for yourself and give yourself small ways to kind of fill your cup while still maybe running around crazy, because that is what at the end of the day is going to keep on happening. I think that totally makes sense.

Dr. Wei: Yeah, I think the goal is to look like you're running crazy, but hopefully on the inside you don't feel that way.

Austen: Yes. It's like the reverse of a duck on water, right? Because the duck looks really calm above . . .

Dr. Wei: Right.

Austen: . . . the water, and below they're running crazy. Hopefully it's the reverse, so inside you're calm even if outside you're running around. I think that makes sense.

And you kind of touched on how there had been a couple of changes since you started your training to now that you feel like have been beneficial. I was curious if there's any one in particular that you felt has been really helpful for you or helpful for your colleagues, as far as preventing burnout, preventing or mitigating the risk of depression, suicide, that kind of thing. Are there any changes that you've noticed that have, you feel like, been beneficial?

Dr. Wei: One positive thing that came from the COVID era is that I think there's more talk about the impact of mental health even more in our world. Physicians are even worried sometimes to put on their medical licensing application that they're on an antidepressant because they're worried that it's going to jeopardize their chances of getting their professional licensing and jeopardize their careers.

And so I think one of the positive things that I've noticed starting from around COVID or a little bit post-COVID times is that there's more talk openly about mental health, the support of utilizing resources. Colleagues from all over are starting to just be open and say, "Hey, I'm seeing this therapist. I support you going to therapy. Taking an SSRI is okay."

Those people are talking more about their mental health diagnoses and the support system that they're getting and trying to help their colleagues find resources.

So that's something that I've noticed over the last few years that has been very, very different compared to when I was "growing up" in this system, in my training.

Austen: I remember applying to med school and being told that I shouldn't talk about any struggles with mental health because schools wouldn't like that and they would look down on me and think that obviously I wouldn't be capable of taking care of people if I had struggled in that way.

And so I'm glad that that's a change you've noticed, that people are more accepting of people being open about their struggles and also, really, it sounds like, willing to support their colleague who need help in that way. I think that's something that's so wonderful.

Sanila, I was curious to get your perspective as someone who, like me, is kind of earlier on in training. I mean, we're more than halfway done with med school, which is crazy, but still earlier on in our training, but then also kind of in your role as one of the representatives for my class to kind of push for change.

I think you have such a cool role in that you go to conferences for the AAMC, you get to talk to them about the things that med students are worried about, you get to kind of advocate for this change. So I'd love to get your perspective as well.

Sanila: How do we fight the system? I guess that's the question, right? It's just a really hard question to ask. This is still something that I'm learning how to do for myself and for others, so I'm by no means an expert.

But I recently read this book called "How We Show Up" by Mia Birdsong. And in it, she talks about the scarcity of time and resources. In applying it to medical school, it's almost as if medical school is a game that we need to win. And it kind of plays into our fear of failure, desire to succeed, and creates what Mia Birdsong calls this real and imagined scarcity of resources, time and money. I think this ends up pitting us against each other kind of in a way.

We often separate ourselves or distinguish ourselves by what we are or are not from what we think others are or not. So when we think someone is hardworking, it means that we also default to the idea that someone isn't hardworking. I think that just creates this inner conflict, at least it does for myself.

I think when we do this, it kind of drains our already existing resources, including time, money, compassion, and then it just creates this exhaustion and it results in this feeling that no amount of time, money, rest is ever going to be enough. I think that's what's difficult.

So I feel like my question is "How do you begin to dismantle that system that's kind of in place to make us feel that way?" And that's a really big question.

Like I said, I'm not an expert. I'm still learning how to say no to a lot of things to create time for myself, and that's something I'm trying to be better at. It's hard to say no, but I think when you do, it creates room for a lot of intentional yeses.

I think practicing kindness for yourself and others also means setting, sharing, and valuing your own boundaries and others' boundaries.

And I think taking accountability for yourself means that . . . It's kind of knowing that when you don't take care of yourself, you rob yourself of the potential of showing up as the best version of yourself for yourself and for others.

I think a small way in which I'm trying to be better about burnout and filling my own cup is building communities around me so that way, other people can turn to me when they're in times of need and that I can turn to others in those times as well.

I really don't think that I would be where I am today without the people that have been around me. In fact, the first time I ever saw my dad cry was when he was talking about how important my friends were. It wasn't about me. But I think that just goes to show how significant those relationships are in your life.

I think the other hard part about burnout is we think that rejuvenating means taking time away from work and going to a "vacation space to rest." And I think while it's good, it's also not really that sustainable, because realistically, how often can you take time away to do things like that?

And in those vacation spaces, that's not where our life is happening, right? Ultimately, we have to leave that and come back to our daily busyness. I think the hard part is finding out how to create time and community and build those relationships where our lives already exist.

But I think that's something important to keep in mind when you're thinking about sustainability in terms of making sure that you feel well enough to care for others and that they feel well enough to care for you.

Relationship-building is something that's really important to me. So a small answer to your really big question.

Austen: I think that was a great answer. And relationship-building is something that both of you have highlighted during this discussion, right?

Sanila: I just want to reiterate that it is really hard to do this in a system that's not built for this. I don't think that this should be another thing on a to-do list of, "Oh, I have to make time for myself. This is something I have to check off," and then I'm going to feel bad about myself if I am unable to meet those needs for myself. I think those needs are not easily met in the world that we live in now. So that's just something to remember.

And I also kind of wish that students felt safe enough to prioritize studying and success without it being at the expense of other things in their life that are just as important, if not more important, honestly.

I also want to say that the fact that this happens elsewhere is not an excuse. I don't think it should be the norm, and I think we can begin to make little changes that kind of take it away from being the norm.

But I feel like if the school expects us to perform above average for them and for ourselves, then it's reasonable to expect the school to perform above average for us too.

So I think it takes fighting these small fires on both ends as students and administration to be able to make meaningful change.

Austen: Yeah, I think that's so well put. Very succinct.

Also, we talked about a lot of small changes that we can make personally. But at the end of the day, we need the institutions that we work within to also be making changes because the small changes that we can make oftentimes aren't going to be enough.

For some people, it may be, and my hope is that for most people it will be. But there are people who are really struggling, kind of quoting Dr. West's letter that was submitted to "The Washington Post," people who are fighting life-and-death battles, and we don't know it. And as much as I wish that small changes would be enough for those people, it ultimately won't be.

So I love how you highlighted we have changes that we can make, but also it is going to be instrumental to work with larger institutions to fight for changes that they can make as well to support us. I love that you highlighted that. Thank you, thank you, thank you, Sanila.

What about you, Dr. Wei? Any last thoughts/comments that you want to bring up and leave with our listeners?

Dr. Wei: I totally agree. I think this self-care . . . there's a lot of talk about self-care, and I think it shouldn't be just this pressure of another checklist item that you have to do. I think these personal changes, hopefully, you learn and build up over time.

But I agree. I think on a much larger scale, our system has to change, which is why I think this conversation that you're bringing up is so important. And I'm just so proud. I think you guys are amazing for third-years to be talking about this.

Hopefully, this is a call for change from everybody, just being like, "There's something wrong here." We need to all be voices for change so that we can have these positive effects on a much larger scale.

So I didn't say it as concisely as Sanila, but I agree with everything she just said. I think you guys are amazing.

Austen: Well, thank you. I think you're amazing, honestly.

This has been such a great discussion for me. I feel like I've learned. I hope that the listeners feel like they've learned. I hope that they feel better equipped to make changes in their life and then also motivated to work with those around them to advocate for changes to this larger structure within which we find ourselves.

I think everyone in medicine, or I would hope the vast majority of the people who go into medicine are here because we want to care for those around us and we want to make sure that the people around us are taken care of. And I think that should extend to making sure that our colleagues are taken care of, making sure that we are taken care of. Hopefully, as more and more people advocate for change, we'll see that change.

I think that will only be to everyone's benefit, whether we're med students, whether we are residents working crazy hours, or attendings in charge of countless patients. I think fighting for change can only benefit everyone within the system.

So thank you both for your perspective, and thank you to the listeners who joined us for our podcast today. Just like with every episode, we appreciate you joining us and we encourage you to come back and listen. You can listen anywhere you podcast, so you can find us on all streaming services.

Thank you for joining us, and I hope everyone has a good day.