
Medical school can be brutal, and it’s making many of us suicidal - snake117
https://www.washingtonpost.com/national/health-science/medical-school-can-be-brutal-and-its-making-many-of-us-suicidal/2016/10/07/faa1a14e-8a4c-11e6-875e-2c1bfe943b66_story.html
======
chriskanan
My wife finished medical school a bit over 4 years ago. While she thought
medical school was brutal, it was comparatively easy compared to the
challenges she faced in residency (she did her prelim at UCLA-Harbor and is
now at Boston Children's hospital doing pediatric neurology). 80+ hour work
weeks are the norm, and sometimes she works 14 days straight and has a pager
that beeps throughout the night that she must respond to before going in again
in the morning.

After one does complete residency, it does seem to get a lot easier based on
observing some of her friends that didn't do fellowships, especially if the
person takes a more clinical job. But after all of that effort, a lot of
people become attending physicians where they are putting in just as many
hours, if not more, because it is more prestigious. Those are the people that
run the teaching hospitals, so it feels like there is a lot of "I survived and
it made me a better physician, you can too" mentality.

~~~
deelowe
As a father whose young son had a compound fracture recently and had to wait
in the ER for 3 hours to get it patched up by a grumpy, rushed, and tired
ortho, this is horrifying.

Something really needs to be done about current crony capitalistic US medical
industry.

~~~
pjlegato
I'm not sure that capitalism as such has much to do with the problem you
describe, as anyone who ever went to a Soviet emergency room will be happy to
tell you.

~~~
gnu8
The Soviet healthcare system suffered from underinvestment due to their
command economy's focus on heavy industry and military production. The problem
in the United States is the exact opposite: unproductive overinvestment due to
the proliferation of waste, fraud, rent-seekers, and all other types of
interests that rake a profit off the top without contributing anything to
patient care. It seems like a false argument to claim that because a radically
socialist regime provided inferior care, our radically capitalist regime is
not the cause of our inferior care.

~~~
stevendhansen
"our radically capitalist regime"

Citation required. I'd venture the US is more accurately described as a hybrid
socialist / mercantilist regime than a capitalist regime.

~~~
thatcat
The US seems more of a militaristic-mercantile regime when you consider the
way the budget is allocated. Sure US has progressive taxes that are pretty
high, but no single payer health care, outrageously priced education system,
and few social safety nets - all indicate a low level of "social ownership
over means of production" which is a defining characteristic of socialism.

------
ReallyAnonymous
medical school is humbling and difficult. Being a physician is difficult. I
finished medical school in 1996 - didn't find it ridiculously hard, but then
again, studying a lot was what I did in my youth. Now, I'm 47 years old, and
work about 90 hours a week as a surgeon - I laugh when people say that we make
too much. All I know is that 25 years ago, you had to be in the top 10% of
your class to become a surgeon. When I applied, it was top 20%. Now, it's
basically if you graduate from medical school and want to be a surgeon, you
can become one. General surgeons put in long hours for not that much glory -
today I waited 2 hrs to drain an abscess that took me 10 minutes, so I got
home at 6:30 pm.

The upside is that when I do a great job, it really is rewarding. The downside
is telling families and patients I do not have much to offer, and their
disease is too far gone. Anyway, don't go into medical school / surgery if you
don't want to work hard. No one has a gun to your head. Physicians that pick
the right profession for their personality / skill set are very happy.

PS my undergraduate degree was computer science

~~~
erentz
Do you _really_ work 90 hours? That's 13 hours a day 7 days a week. How does
that even work logistically when you need to eat, sleep, commute, do laundry,
shop for food, and hopefully also see family or friends on occasion.

~~~
northern_lights
I am nearing the end of medical school now, and I can assure you there are
many surgeons who consistently work 80-90 hours/wk. I see it most often in
surgeons who have subspecialized and do _extremely_ technical work. Family,
social, laundry, food, etc, all become things that you take care of whenever
you get a free second. It's very, very difficult to describe the path a person
takes to get to that point, but the profession can absolutely be all-
consuming. It's one of the reasons surgery is less competitive as a specialty
than it used to be - people see the brutal hours and make the choice to pursue
options with a more attractive work-life balance.

~~~
sp332
Isn't that a little backwards though? The more surgeons there are, the more
the work could be spread out, and the hours would be saner.

~~~
northern_lights
1.) It's a very time-consuming and hands-on process to train a surgeon. There
aren't many other fields that I'm aware of with the same level of intense
apprenticeship as surgery (and medicine in general). My first thought after
entering medicine was to marvel at how much effort goes into training a single
physician. There is a _lot_ of training at between a 1:1 - 1:3 student-
preceptor ratio in an effort to produce very high-quality physicians. So, the
solution is not exactly as easy as, "well just make more surgeons."

2.) The federal government controls the number of residency slots each year,
through Medicare funding for residency programs. I don't pretend to know the
details of how it works, but my impression is that to get more residents per
year, you need to convince Congress that it's necessary.

3.) Classic chicken-and-egg problem. Any medical student can go into surgery
if they want to, unless their performance up till that point is seriously
below par. However, there are many other specialties that offer more
attractive lifestyles. So to increase the number of students who choose to do
surgery, you'd need to find a way of signaling to students that the life of a
surgeon isn't all back-to-back divorces, microwave dinners, and 80-90hr work
weeks.

~~~
JBlue42
Q's re:

#2 - If Congress were convinced of that, would that help lower medical costs
for patients or possibly increase it? That's assuming without some sort of tax
increase to pay for it.

#3 - I guess this why I've heard that dermatology is one of the most
competitive fields to get into - good hours, not as much stress, and good pay.

------
jseliger
I wish more people knew and understood this. I didn't write about the suicide
angle specifically, but I did write, "Why you should become a nurse or
physicians assistant instead of a doctor: the underrated perils of medical
school:" [https://jakeseliger.com/2012/10/20/why-you-should-become-
a-n...](https://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-
physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-
school/), which covers similar topics.

~~~
Spooky23
Nurse practitioners and PAs have it made these days. Great pay and crazy
flexibility and job prospects.

My sister in law got annoyed about changes at her workplace with respect to
scheduling. She griped about it in the break room, word got out and she had
three unsolicited, real interview offers by the end of her shift.

Her requirements were to get her kids on the bus and be home at 5PM. That's
written into her employment contract, along with a significant raise and
retention bonus.

------
cm2187
One thing that strikes me is that the medical profession is one of the only
professions that hasn't industrialised. Basically one highly paid, highly
trained doctor in front of every patient. It's a craft industry... It doesn't
scale well, and it is very hard to maintain a consistent quality.

Perhaps will AI change that...

~~~
dnautics
? Every patient is exposed to a surface area that comprises several doctors.
Currently my father is hospitalized with a failing liver and kidneys. He sees
a GI doc, a liver doc, a kidney doc, an anaesthesiologist, residents for each
of these, an intensivist.

~~~
cm2187
I had more the generalist model in mind, as many small problems could
certainly be dealt with in a more automated way. But the example of your
father is illustrating my point. All these professionals each individually has
to stay up to date on all the developments in their profession. And you hope
they were not bottom of their class, barely making the exam.

For complex medical problems, algorithms are unlikely to do it for many years.
But to recognize common skin diseases for instance it is perhaps not so far
fetched.

~~~
epmaybe
As a medical student, I bring the AI future up a lot. For some reason, my
fellow students immediately assume I mean general AI, where it somehow assumes
all roles of a physician.

What I always try and explain to them is that there are definitely solvable
problems in subsets of medicine like dermatology. Sure, it'll probably take 20
years before there's any traction, but there's no reason to completely dismiss
the idea either.

------
cylinder
The presence, or increase, of suicides does not mean that medical school is
too "brutal." It could very well mean that young people are becoming worse at
coping with stress. Or perhaps students feel more pressure because of their
perceived consequences of their failures: basically no alternative career path
that would provide the same standing as medicine, whereas in previous
generations, med school dropouts could go on to dental / law / cushy corporate
gig more easily. This could be one of the consequences of rising inequality.

I'm not disputing anything here, just want to discuss this logically. I've
been in graduate school, and it wasn't that hard, and yet some of my peers
would freak out constantly. And some wouldn't.

I will say that there's definitely a hazing culture across all professions in
America that's completely unnecessary and inappropriate.

~~~
sparky_z
"I will say that there's definitely a hazing culture across all professions in
America that's completely unnecessary and inappropriate."

I'm a structural engineer. I don't recall any sort of hazing culture, or even
a single instance of hazing.

~~~
LeifCarrotson
Where did you do your internship, and what were you asked to do there? How
many hours did you work and study while in school? Were you expected to work
much longer hours as a junior employee to "work your way up the ranks?

I think these are the sorts of elements of a hazing culture that GP is
discussing. Not necessarily fraternity-prank style hazing.

~~~
cylinder
Yes, this is the type of hazing I am referring to. Call it "institutionalized
hazing" rather than fraternity style hazing. The bar exam for lawyers is one
good example of hazing. Most law grads who apply themselves will pass, it's
just a form of hazing for new entrants. Other countries with common law have
just as good, if not better, bars and they do not have postgraduate law
degrees and bar exams to become admitted. I don't buy the "it reduces supply"
either, because of the high pass rates, but even if it was used for this, it
would simply be injustice. If you want to filter people out, do it _before_
they waste three years and $150,000.

~~~
nijiko
What is your plan to replace these to filter out or vet people prior to
learning the knowledge required to sufficiently do the jobs they trained their
minds to do during those years?

I am curious, also, to these other countries that have better bars, can you
cite some countries and studies that back up these allegations?

------
jimmywanger
I see parallels with medical school in tech hiring.

They put the students through hell because that's what they had to go through,
and they're rent seeking.

In most other countries, doctors don't have an accreditation board. Most
things are simple, and it doesn't require years of school to set a bone or put
in some stitches, or even diagnose the flu or pneumonia.

Similarly, you don't need a rockstar or ninja to write your CRUD app. Anybody
who knows what he's doing will be able to do that, he doesn't need to be the
best of the best, he just needs to be competent.

~~~
rifung
I have a friend in med school and his experience doesn't sound like tech
hiring at all. From what I can tell, med school isn't hard because of rent
seeking, but because there is frankly just a very large amount of things you
have to learn in a short amount of time. They also have to work extremely long
hours on certain rotations. I was shocked at how little sleep he could get on
some days.

On the other hand, he seems to not have experienced the bullying described in
the article, so maybe that part of it is the rent seeking you describe.

I do think that tech hiring is a little ridiculous at times, but if doctors
mess up, people sometimes die. It would make much more sense for them to go
through accreditation like engineers do, in my opinion of course.

~~~
kcanini
Doctors do go through an accreditation process:
[https://en.wikipedia.org/wiki/United_States_Medical_Licensin...](https://en.wikipedia.org/wiki/United_States_Medical_Licensing_Examination)

~~~
rifung
The person I was replying to mentioned that some other countries don't have an
accreditation board. I was trying to imply that I approve of its existence,
not that there isn't one. Sorry for the misunderstanding.

------
drcross
Many people want the status associated with being a doctor (of course some are
pushed that direction by parents and some also just want to help people). When
you have an abundance of people trying to get into an industry the profession
have the ability to only choose the absolute pinnacle of talent. It's the same
with being a pilot. Many of them work long hours in shit conditions for years
hoping to get a decent route. I have often had notions of throwing my career
in to be a Doctor but the price you pay to climb to the top of the heap is not
worth it, long hours, student loans, bad pay for the first decade, no social
life, worry about malpractice, make it simply not worth the tradeoff for some
status and job security.

~~~
PhasmaFelis
How much longer until programming is the same way, now that we're pushing it
to every kid and idolizing tech billionaires?

~~~
jimmaswell
From what I've heard, the vast majority of people just can't understand the
kind of thinking required to be a programmer. The rate of application to
Computer Science programs has increased, but it has the highest dropout rate
among other subjects, which is said to be because of the problem of
programming requiring a certain predisposition.

One of a few articles on the subject:
[https://blog.codinghorror.com/separating-programming-
sheep-f...](https://blog.codinghorror.com/separating-programming-sheep-from-
non-programming-goats/)

I've personally found it to hold in a few instances where I've been able to
observe different people trying to learn programming - they seem to either
understand it right away or not really get it. A Computer Science professor of
mine said this same thing once - he said "it's an aptitude."

~~~
Spooky23
I disagree with that. I think the quality of CS education is pathetic.

I've been an adjunct instructor at a local university, and they hire industry
people because they don't have enough grad students who can teach or don't
speak English sufficiently to teach. The kids are great and can do anything,
but they are stuck in a brain dead curriculum that's designed to haze them out
before their junior year.

------
naveen99
> average acceptance rate for fall 2015 was 6.9 percent

But most students apply to multiple schools. Actual acceptance rate is 40%
across all demographics.
[https://www.aamc.org/download/321480/data/factstablea12.pdf](https://www.aamc.org/download/321480/data/factstablea12.pdf)

Edit: also, 25% of the applicants are repeat applicants. So, first application
acceptance rate is probably closer to 50%.

~~~
cloverich
Though its worth mentioning that based on your grades, test scores, and even
pre-med screening -- many students who _want_ to be a doctor will never even
apply.

------
seanseanme
I just finished residency and, based on my experiences, I have three points.

1) This situation seems analogous to the higher rate of suicide in very
competitive colleges. Both feature putting people who did very well in the
prior stage and then demanding a high level of content mastery in a short
period of time. Interestingly, some places a pushing for a 3 year med school
experience for primary care to reduce loan burden and get more productive
years out of the training. I wonder how this will affect this pressure.

2) I wonder if discussing the harsh reality of medicine - charting, team
management, things being beyond your control - rather than emphasizing the
'higher calling' and 'privilege to care' would dissuade those seeking prestige
form entering medical school. I think it is a much greater service to have
them figure out before school starts and not be saddled with 40-50k of debt
that first year.

3) A big transition I always heard in med school was the difference of the
trainees in that they value work/life balance much more than the titans of
medicine in the past. How to rectify this priority with traditional medical
school is a VERY interesting question.

------
rifung
> . Fortunately, others are speaking up as well. In online magazines and on
> NPR, medical students who have lived through suicide attempts, depression
> and other mental-health issues are standing up against this stigma. Medical
> schools are now training faculty to recognize risk factors for suicide and
> assuring students that seeking help isn’t a sign of weakness.

I wonder whether and hope that mental illness will end up like homosexuality
in the sense that people will no longer have to hide who they are. On the
other hand, I suspect that would be a more difficult battle, especially when
it comes to employment discrimination.

~~~
cloudjacker
San Francisco is a sanctuary city for counterculture. As more counterculture
becomes acceptable outside of sanctuary cities, more marginalized people
remain or come to the sanctuary cities partly due the history of catering to
marginalized people.

I think that would be a decent way for you to see a possible outcome in that
field too in order to create a conclusion.

~~~
Swizec
> San Francisco is a sanctuary city for counterculture.

As long as your type of counterculture doesn't involve the perceived potential
of underperforming. Then you're out. Because meritocracy and stuff.

Mental illness is almost always perceived as "Oh shit, this person isn't gonna
be a top performer"

------
mmagin
This is the important part, I think:

"But one part of medical school culture has been especially hard to overcome:
the stigma of mental illness. When they need help most, medical students in
anguish rarely reach out. Students attribute this reluctance to seek care to
fear of stigmatization by peers and to concerns over professional
ramifications, particularly during applications for residency and licensing."

~~~
LeifCarrotson
Interesting they say they attribute it to stigmatization and judgement.

What I have observed among family in the medical industry is a reluctance to
use the care they provide: not just Do-Not-Rescusitate orders but a tendency
to just suffer through the sickness instead of seeking medication, and to let
the illness take its course rather than seeking second opinions and treatment.

Of course, these are with regards to physical ailments. Family has been much
less public about mental issues. But I wonder if these same fears and
proclivities also translate to mental health problems.

~~~
tcj_phx
> What I have observed among family in the medical industry is a reluctance to
> use the care they provide: not just Do-Not-Rescusitate orders but a tendency
> to just suffer through the sickness instead of seeking medication, and to
> let the illness take its course rather than seeking second opinions and
> treatment.

Sometimes the treatment is worse than the disease.

> Of course, these are with regards to physical ailments. Family has been much
> less public about mental issues. But I wonder if these same fears and
> proclivities also translate to mental health problems.

Most mental health medications are palliative, and tend to make the underlying
condition worse over time [1].

[1] [https://www.madinamerica.com/anatomy-of-an-
epidemic/](https://www.madinamerica.com/anatomy-of-an-epidemic/)

------
paviva
Compared to previous generations (and the change is quite steep -- I am
talking about students today vs. students 5-10 years ago), a growing
proportion of medical students have entitlement issues.

Those issues are roughly two-fold : (1) feeling entitled to a "balanced"
lifestyle; (2) feeling entitled to help people. The first one is obvious:
student want to leave early, they don't understand that patients always come
first, that, sometimes, you have no choice but to be sleep-deprived for days,
and so on.

The second one is a kind of "Mother Teresa Complex" when students experience
uncontrolled anxiety and distress upon seeing a fully competent adult actively
undermining his own care. I see it all the time when they try to talk a lung-
cancer smoker into stopping for 30-40 minutes, come back almost crying that
he's not interested, and can't believe that their "trying to help" means they
are now late, and I'm not happy at all.

~~~
alasdair_
>"Mother Teresa Complex"

Wouldn't this mean simply telling the patient that their suffering is "God's
plan" and refusing to treat them, nor give them any pain medication?

~~~
paviva
Thus is hyperbole, of course -- hyperbole which serves to highlight that
refusing to allow the patient to decide for himself, trying to force your own
outlook "for his own good", is exactly the same as not giving pain medication
because it's against some religious ethical code.

------
naveen99
> "I checked the medical licensing requirements in California to make sure I
> wouldn’t lose the ability to care for patients... Fears were unfounded."

You should get help. But you can't be sure you will be allowed to practice
medicine. The medical board will decide on an individual basis. For reference,
texas medical board form for mental illness and self referral program:
[http://www.tmb.state.tx.us/dl/C5EAB589-0916-C88D-FF94-DE8D96...](http://www.tmb.state.tx.us/dl/C5EAB589-0916-C88D-FF94-DE8D9623C5A4)

Of course, if you don't self report, and practice anyway, and a patient
complains, you might be facing criminal charges.

First do no harm. Help yourself before you help others (seek mental help if
you need it).

------
s_q_b
My sister is currently finishing medical school at Penn. We talked about
suicides in hospital and university settings.

She had an interesting perspective on the problem. She said that it isn't the
intensity of the work, the academic rigor, or even the emotional damage from
constant exposure to death and disease.

It's the sleep deprivation.

There is a very large amount of evidence that one night of reduced sleep
massively increases medical errors. Despite this knowledge, sleep deprivation
remains this massochistic macho hazing ritual, which increases in severity
through residency.

It's dangerous and unnecessary.

This article does a good job of capturing the chain of internal events that
lead from exhaustion to burnout to severe depression and finally to suicidal
ideation.

------
glup
My partner studies how and why mainstream hospitals are turning increasingly
to complementary and alternative medicine (CAM). Interestingly, one reason is
that many current doctors burnt out (because of the conditions described in
the article and developed chronic and/or psychological conditions either in
med school or practicing. These doctors (or soon-to-be-doctors) find that CAM
offers better remedies for many chronic conditions, which the current
biomedical stack really isn't optimized to handle. Then when they finish med
school, they're in a privileged position to confer institutional legitimacy on
CAM treatments. So in some sense, this brutality is changing medicine more
generally.

------
choward
I just skimmed the article but is there any comparison of current suicide
rates to previous suicide rates? If not, this article is pointless.

------
ukat
I love the medical school analogy "drinking from a firehose" since a lot of
the knowledge has to be frontloaded. This makes sense since making errors is
less forgiving.

software engineering might be closer to "drinking from a running facet..
forever". I know doctors have to keep learning but I always wondered if it was
more or less than engineers after school.

------
elijahparker
A company I used to work with makes a program [1] for monitoring medical
student well-being over time to try to detect early warning signs as well as
provide anonymized data for research

[1] [http://www.mededwebs.com/well-being-index](http://www.mededwebs.com/well-
being-index)

------
ljk
I wonder if the high salary is worth the mountain of debt on top of all this.

Could part of reason why the education is so expensive due to the monopoly in
all the tests med students have to take?
[http://endstep2cs.com/petition/](http://endstep2cs.com/petition/)

~~~
trgn
Of course it is. The size of medical school debt is about the size of a common
mortgage. That's no burden at all for a deep six-figure salary. It's a total
non-issue.

------
mhb
A med school student's contemporaneous journal describing his time in med
school:
[https://news.ycombinator.com/item?id=12680306](https://news.ycombinator.com/item?id=12680306)

------
samfisher83
If you get into med school especially if you are Asian means you are pretty
competitive. You basically need a 3.8 GPA and about 31 to get into an average
med school. If you get into a specialty you are making close to 250-300k+
starting. Obviously its going to be competitive. Its basic economics.

------
smnplk
"You are grounded until you become a doctor!" \- One chinese dad to his young
son.

