I have never met a medical student that did not want to help people.
I have never met a medical student that did not have plans to make lives better. And the reason for that, I think, is obvious: the long, arduous journey to a licensed physician is only bearable when you have passion to hold on to, when you have passion to look to and tell yourself these years will be worth it because one day, you will be who you said you would be; one day, you will be the physician your patients deserve.
And yet, I wonder why it has to be that way.
Why is it that we know medical students are more at risk for depression than the average population1, but medical school curriculums have largely remained the same? Why is it that we know medical student burnout is associated with lower levels of empathy2-3, but nothing seems to have changed to address it? It feels as though it all keeps coming back to the same word, the same concept that has become so intricated into the fabric of medicine, the two appear inseparable: sacrifice.
Every medical student, every medical resident, has heard it an infinite number of times in their career: the honor of their sacrifice, the necessity of their sacrifice. I trace it in my mouth sometimes, wonder when its meaning twisted. At one time, I too said it proudly, told my peers I was sacrificing my twenties so I could love my work for the rest of my life.
It is still true; I still hold onto that now, when I watch my friends buy their first car, watch them celebrate their promotions, watch them put down roots with the sort of surety that comes from control over your future. I watch them achieve their dreams while I pursue mine, and I am happy for them. It is a sweet kind of happiness, the kind that comes from having seen their journey and knowing they are rooting for you in yours. And I am happy for them because this is a sacrifice I can accept, a sacrifice that I chose. This is a sacrifice I understood when I first set my sights on medicine, a sacrifice that makes me eager to pursue the things I can only do now, the things that I may not have time for outside of academia.
It reminds me that life does not have to be a sprint all the time, that sometimes, maybe especially when the path is a little more gravelly, a little less smooth, it is important to slow down, to appreciate the pebbles holding up your feet and the path you have chosen, even as you look forward to the path ahead.
So this is not the sacrifice that prods me when I am hunched over my laptop at 3:00 A.M. telling myself I will fix my sleep schedule tomorrow. Rather, it is when I turn on the news and see the latest in a long line of physician deaths, the preventable kind, the kind that I should not have to mourn because it should never have happened.
It is when I see physicians looking for work in the middle of a global health pandemic because their voices were too loud, carried too much when they protested a lack of protective equipment4-5 and a further lack of support from hospital leadership. It is when I see medical institutions focusing on the “heroism” of their sacrifice, rather than on the puzzling need for it in the first place. It is when I see that even in the midst of this grief that has left none of us untouched, college students, including medical students and residents, are struggling to have their frustrations heard by administrations that promised empathy.
Of course, the pandemic is not something any one person, or even any one organization, can shoulder the blame for. Perhaps it would be satisfying to be able to say that hospitals should have known, that they should never have left their workers without the protection they should have been guaranteed; Perhaps it would ease some of the ache to be able to say that colleges, that medical schools should never have opened at all if they could not promise safety and an unwavering standard of education.
But it is impossible to forget that there is so much humans cannot control. After all, it was one of the things that drew me to medicine in the first place, that where death is inescapable, maybe I could still help fend it off for someone, even just for a little bit. So hospitals cannot solely be blamed for pandemic preparations handled by federal and state governments, and higher education cannot solely be blamed for life needing to go on.
But what seems to be overlooked is that this is not what they are being blamed for in the first place. Medical student burnout, and for that matter, medical resident and physician burnout, is not new information, cannot be cursed on COVID-19. Conversations about lack of empathy among physicians and its correlation with burnout in medical education1-3 have been going on for years, and yet that is the crux of the issue.
How long will conversations stay conversations? How long must students wait for words to become actions? It takes four years of medical school and three to seven years of residency at minimum to practice as a physician in the United States; that is no short amount of time that medical students and residents are subjected to medical education. It should be obvious that change needs to originate at the medical curriculum level, and it should be clear that there is no one better to speak about student concerns than students.
And yet, curriculum changes continue to exclude student voices. And so curriculum changes will continue to exclude the changes that are necessary for students. For example, mandatory wellness classes can only be seen as performative when schools do not change the rest of their medical curriculums to reflect any regard for their students’ mental wellness.
Could someone who does not remember the panic of first-year more accurately assess the wellness that first-year students need than students themselves? Could someone who has long since left residency, or perhaps never experienced it at all, be better suited to deciding working conditions for medical residents than the residents who are living it?
And here is the root of the issue once again: sacrifice. Whether purposeful or not, there is a culture fostered in medical institutions of equating professionalism with silence5. We speak loudly for our patients; there is no timeline on this Earth where I could allow myself to do less than everything possible to work towards making healthcare accessible and equal for every patient.
So why is it we must instead be cautious when we want to advocate for ourselves, within medicine, within the workforce? Is it so bad if medical residents complain that their pay is not on par with mid-level healthcare practitioners in the same hospital7? Is it so bad if medical students want to be involved in the discussion on mental wellness and its proper, effective inclusion in medical curriculums1? Because who better to advocate for ourselves than us?
Maybe this is what makes it more frustrating than usual to hear the stories of so many healthcare workers that have said their choice to speak about unsafe working conditions during COVID-19 was met with frigidity and, in some cases, unemployment4-5. Because while hospital administrators cannot shoulder all the blame for not having enough PPE on hand, it is certainly reasonable to expect that they would be the first to advocate for their healthcare workers’ safety, the first to value transparency and lend a listening ear.
Physicians and other healthcare workers were looking for support, for a leadership that would acknowledge the difficulty of their work at this time and offer them their shoulders to lean on and their resources to amplify workers’ needs8-9.
But in fact, studies8 assessing health care workers’ anxieties due to COVID-19 found that many of their concerns stem from a lack of trust that their organization will care for their safety and for their loved ones should the healthcare workers’ become infected, with a large concern being that rapid testing often isn’t even available for healthcare workers that are exposed to the virus every day. To be met with punishment4 rather than support from the leadership at their own organization, and towards physicians and healthcare workers in the midst of a global health pandemic no less, only points to a larger issue that seems to have been brushed over in the haste to name healthcare sacrifice heroic.
This is the diffuse issue that arises with using language that correlates sacrifice to medicine. Instead of being the harmless celebration that the phrase “healthcare heroes10” was likely meant to be, it instead has become a means to push responsibility onto healthcare workers, especially physicians, for a pandemic that should have been handled at a higher level. Because when someone is a Hero10, you don’t have to worry. They will handle it. They will take care of it. But this is not something that physicians can take care of on their own.
They are not heroes; they are humans like the rest of us, struggling with the added pressure of idealism and unrealistic hopes of a public desperate for heroes. Research already shows us that the burden of heroism10-11 causes workers to internalize concepts of an ideal worker to the point of burn out and being unable to ask for help.
Reciprocity is absent in heroism, and that is why it is such dangerous language; to give and give but not be able to ask in return is too dangerous to be made an expectation in medicine. Almost no career sees this illustrated more vividly than in physicians, who are infamous for difficulties in seeking help for themselves due to internalized stigma that they are only worthy of giving, not receiving11.
To be clear, every medical student, including myself, knows that to be a physician, to be a healthcare worker of any kind, means to accept a level of risk every day. Medicine is not easy; safety can never be guaranteed 100%. But what can and should always be guaranteed is that as physicians, as medical students, in a dangerous field, we should always be given the best protection possible and the full support of the leadership around us to perform our jobs, that we should never be treated as expendable bodies.
In a career that works so tirelessly to prevent death, it is almost too easy to become detached to the ache of death; it is almost too easy to demote the heartbreaking end of the decades of work in the journey of a physician to a hero’s sacrifice, rather than to address the negligence towards health care workers4-6 that created such a sacrifice at all.
Sacrifice should never be an expectation, and we should be careful in our language not to laud it as an aspiration. Heroism does not need to be normalized in medicine because we are not superhuman; we bleed just like everyone else. We do not need to be physicians that sacrifice. We need to be physicians with the resources to help as many people as possible, to the best of our abilities, while remaining safe ourselves.
I entered medicine knowing that there is no short-cut to becoming a physician. And I am proud of that, of knowing that I am building something that can only be built with hard work and perseverance. I will always be proud to lend my hands to a career whose existence revolves around creating a better life for more people. I hope that one day that can be the focus in medicine, that work ethic, that unmatched love for what we do, rather than a hyper-fixation on sacrifice and heroism.
Because I will sacrifice my time; I will sacrifice my sleep; I will sacrifice the opportunities that others my age enjoy. But I will not be a scapegoat hero5 to deflect from the very real issues plaguing healthcare as a system; I will not accept a sacrifice that risks my life for empty platitudes instead of much-needed change towards an environment open to constructive criticism. And so I cannot wait for the day that I can call myself someone’s physician, but I will never be anyone’s sacrifice.
I am not your hero.
- Moir, F., Yielder, J., Sanson, J., & Chen, Y. (2018, May 7). Depression in medical students: Current insights. Retrieved September 20, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944463/
- AK. Brownell, L., Halpern, J., M. Hojat, J., RA. Diseker, R., M. Hojat, S., LM. Bellini, J., . . . Oswald, P. (1970, January 01). How Do Distress and Well-being Relate to Medical Student Empathy? A Multicenter Study. Retrieved October 27, 2020, from https://link.springer.com/article/10.1007/s11606-006-0039-6
- Brazeau, C. (2010, October). Relationships Between Medical Student Burnout, Empathy, and … : Academic Medicine. Retrieved October 27, 2020, from https://journals.lww.com/academicmedicine/FullText/2010/10001/Relationships_Between_Medical_Student_Burnout,.12.aspx
- Bernard, R., MD. (2020, May 11). Coronavirus pandemic demonstrates disconnect between executives and doctors. Retrieved September 20, 2020, from https://www.medicaleconomics.com/view/coronavirus-pandemic-demonstrates-disconnect-between-executives-and-doctors
- Khan, M. (2020, April 20). The Problem With Heroizing Health Care Workers Like Me. Retrieved October 27, 2020, from https://newrepublic.com/article/157354/problem-heroizing-health-care-workers-like
- Murphy, B. (2020, November 17). Physicians shouldn’t face repercussions for speaking out on PPE. Retrieved November 18, 2020, from https://www.ama-assn.org/delivering-care/public-health/physicians-shouldn-t-face-repercussions-speaking-out-ppe
- Landi, H. (2020, August 25). Most medical residents are dissatisfied with their salaries. Here’s how much more they want to be paid. Retrieved September 21, 2020, from https://www.fiercehealthcare.com/practices/most-medical-residents-dissatisfied-their-compensation-here-s-how-much-more-they-want-to
- Tait Shanafelt, M. (2020, June 02). Understanding and Addressing Anxiety Among Healthcare Professionals During the COVID-19 Pandemic. Retrieved October 27, 2020, from https://jamanetwork.com/journals/jama/article-abstract/2764380
- Arnsdorf, I. (2020, March 31). A Major Medical Staffing Company Just Slashed Benefits for Doctors and Nurses Fighting Coronavirus. Retrieved October 27, 2020, from https://www.propublica.org/article/coronavirus-er-doctors-nurses-benefits
- Cox, C. (2020, August 01). ‘Healthcare Heroes’: Problems with media focus on heroism from healthcare workers during the COVID-19 pandemic. Retrieved September 21, 2020, from https://jme.bmj.com/content/46/8/510
- Putnik, K., Jong, A., & Verdonk, P. (2010, February 10). Road to help-seeking among (dedicated) human service professionals with burnout. Retrieved October 27, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S073839911000011X