The History of Medicine Can Help Us Unravel Toxic Medical Culture

Understanding how our medical culture formed is an important step in unraveling the toxicity that has led to burnout and dissatisfaction, and toward building a sustainable, fulfilling, and joyful profession we can be proud to practice. 

Using some of the information in this paper on the historical perspective on obstacles to physicians’ emotional health, this week’s podcast episode takes a deep dive into the origins of some of our problems, and some possible solutions.

The paper’s authors propose three main categories of obstacles that have arisen as part of medical culture:

• Medical exceptionalism: the idea that being a physician is so special that WE have to lose ourselves.
• Medicalization of mental health issues: the idea that physicians with any mental health issues are “sick” and “impaired.”
• Individual responsibility: the idea that the responsibility for dealing with mental  or physical health problems, or one’s own wellbeing, resides solely with the individual, and not the institution. 

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Transcript

 season 2 episode 3

[00:00:00] 

this burnout problem we all have is it's in the medical culture, but it's seeped into us and we're going to have to figure out how first to change us so that we can then change the system because nobody's coming to fix this for us. It will not happen if we don't choose to do something about it.

[00:01:00] 

Hello friends. Welcome back to another episode of women physicians, flourish podcast. I'm so glad that you're here and I'm so glad to be here with you today. I am all ready I've got my lipstick on which you can see if you watch me on my YouTube channel and I've got my fan club t-shirt but I'm not going to tell you where it's from.

If you watch and you know where it is and you DM me, I'll give you a million cool points, which are worth nothing, because being cool is lonely. Seriously, if you know where the shirts from may give you a little, here we go. You can see it. It's like my placebo effect when I wear my t-shirts that I love when I'm recording podcasts.

 I heard from a lot of you last week about, the episode [00:02:00] on physician value self-valuation and resilience. I think it resonated with a lot of you, this idea that we don't have a problem with resilience. We're very resilient. but the seems to lie in the way that we act toward ourselves.

And that impacts our ability to, to deal with the issues in our workplace that lead to burnout. So burnout is always occupationally induced. I will never ever victim blame. But the culture of medicine seeps into us from the very first day of medical school, you know, it seeps in, and we learn. Not to practice self valuation. We learn that it's wrong. We get shamed for it. So today what I want to do is talk to you more about [00:03:00] why, why do we not value ourselves? Why do we have difficulty with self-condemnation? Why do we not take care of our own health? Why do we feel like meeting our own needs is incompatible with meeting the needs of our patients. So to start with, if you'll remember last week, I mentioned that. The authors of those two papers.

And if you didn't listen last week, I strongly encourage you to go back and listen to that. This is going to make a lot more sense to you, and that is deeply impactful information. So I want you to have that. So there's a supplement published along with. The second paper and it's the self valuation scale, the questions that they asked and then rated on a Likert scale, to measure how well the physicians and then the general population care for themselves and also their mindset with respect to setbacks and [00:04:00] challenges.

The four questions that are in that assessment are one. When I made a mistake, I felt more self-condemnation than self encouragement to learn from the experience. Number two, I was less compassionate with myself than I was with others. Number three. I put off taking care of my own health due to time pressure and number four, taking care of my needs seemed incompatible with taking care of my patients' needs.

And if you remember from last week, the scores on this instrument had a direct correlation to burnout rates, an inverse association. So the, the worst self value, the worst, the self evaluation score, uh, the worst, the burnout score. And they were like a one point to, one point correlation is really interesting how that worked.

And then in the general population they found that there was a significantly [00:05:00] higher self-valuation score and. Corrected for self-valuation in physicians, the burnout rates equalized with the general population and actually got a little better. And when you separated out men and women in the physician group, the self-valuation scores were worse in women.

And when you corrected for those, they almost completely corrected the burnout rate difference between men and women physicians. Big, big thing. Really important. Because again, this burnout problem we all have is it's in the medical culture, it's in our practices, but it's seeped into us and we're going to have to figure out how first to change us so that we can then change the system because nobody's coming to fix this for us. It will not happen [00:06:00] if we don't choose to do something about it. The next paper that I want to share with you, you hear my rustling, sorry about that. The next paper that I'm want to share with you is fascinating to me because I love hearing the history of things.

Sometimes it can make all the difference to know why something is the way that it is. And so this paper really helped me with understanding. This is from new England journal medicine's January 6th, 2022 issue. And it's a history of medicine article titled "obstacles to physicians, emotional health: lessons from history" and it was written by Agnes Arnold, foster Forster, Jacob Moses, and Samuel Schotland so what they do is they lay out what they consider to be three main historical obstacles to physician's wellbeing. And these are in no particular order, [00:07:00] one medical exceptionalism. The idea that medicine is this extraordinarily self sacrificing profession that confers social privilege and prestige, but also has downside.

As we all know, and we'll talk a little bit more about then medicalization of mental health or substance use problems. This idea that any physician who has a mental health or substance abuse issue is sick and impaired and must be treated as if there's something wrong with them.

And that it is them that needs to be fixed, not the system. And then number three which ties into that is individual responsibility. This idea that physicians are personally obliged to maintain their own wellness and that it's not really even considered that there are institutional causes or institutional interventions that need to [00:08:00] happen to keep physicians from being Unwell.

So let's talk about medical exceptionalism. back in the, oh, by the late 18 hundreds physicians in the United States didn't have the best reputation. There were there were some great schools and then there were lots of people who popped up. With medical schools that had, no real validity, they were snake oil, salesmen, and quacks, and there was not regulation of medical education in the United States.

And, the general public knew that a lot of physicians or people who called themselves physicians we're just quacks. And in 1910 Flexner wrote the Flexner report, which was a scathing review of medical education in the United States. And it led to major reform in medical education. It became more standardized and [00:09:00] regulated, and it became later on in the 19 hundreds it became. More respected profession. And so later on into, the 19 hundreds, it became a highly respected profession and physicians were thought of as humanitarians and people who were committed to the public good. And They became identified with the sense of being called in to a vocation rather than this just being a regular job, like other people might have. And many of you listening, probably identify with that. I know that I do medicine is not just a job for me. It's a calling, but This led to physicians buying into this idea of self negation in order to be physicians.

So here's a quote that's quoted [00:10:00] in this paper in 1890 there was the governor of Kentucky told the graduating class of the Kentucky school of medicine, this , quote: no other calling demands a more absolute self negation than the one you have chosen. No other vocation, not even the sacred ministration of religion itself requires a more constant exercise of the higher faculties of the human mind or more earnest devotion of the pure and nobler attributes of the human soul. unquote

In the American academy of family physicians section on their website called considering medical school. They say medicine's not for everyone. As most physicians find that medicine is a vocation that requires a commitment to service, lifelong learning, and the dedication to practice competently and compassionately.

So this is admirable, right? To practice competently and compassionately, [00:11:00] lifelong learning and service. But you heard that self negation giving up who you are. Your own desires and likes and dislikes your family, your relationships, your sleep, sometimes your sanity.

I, I would argue that self negation is not a good thing. Self negation is only a good thing for whoever's up the chain who's not having to self negate. Self negation makes people susceptible to abuse. Right. And sometimes even keeps us from being able to think logically when it comes to ourselves, makes us more susceptible to being influenced by people who would, manipulate us

So that's the first historical obstacle to physicians wellbeing, medical exceptionalism. So the next one is medicalization. So in the 1950s there began to be some [00:12:00] awareness of issues with physician mental health and began to become a problem that was felt that

the medical societies, needed to address, but the way that it was addressed was really just focusing on the idea of the impaired physician. And there were even laws that were enacted in several states. They called sick doctor laws. Anybody want to guess what states those were Florida and Texas.

Sorry guys. I'm in Mississippi. We don't do so great legislatively, but Florida and Texas, y'all been leading the pack lately. I feel for you. Those statutes empowered medical boards to investigate and suspend physicians for, just for a mental health diagnosis or substance abuse. Regardless of the severity of their condition.

Later on in the seventies, the AMA had a series of conferences that were dedicated to physician impairment. There were a lot of [00:13:00] local and state Organizations that really focused on physician impairment and eventually evolved into what today are physician health programs, which are in most cases.

Wonderful. But, but there was this focus on mental illness depression burnout being a problem in the physician, it was a medical problem. There was something wrong in that person. And it kept the focus from being on the institution of medicine, of the culture of medicine. And it became, the individual's responsibility to, get fixed basically.

So also in the sixties and seventies, there began to be some emphasis on. Wellness and wellbeing as an alternative to a focus simply on eliminating pathology. But unfortunately many of those programs really stressed the idea that, [00:14:00] individuals need to assume more responsibility. And so that sort of spills over into.

Third historical obstacle to physician wellbeing, which is the idea of individual responsibility. So considering physicians personally obliged to maintain their own wellness, which then requires very little be altered about existing work conditions or the toxic culture of medicine. Even today we see this happen in a lot of corporate wellness programs and Burnout prevention for physicians and healthcare workers in general, that are focused on individual responsibility. You know, you need to practice mindfulness, you need to sleep more. You need to make sure that you're taking care of yourself.

And there's no real room for discussing the root problem, the root cause and the root cause is deep. it is deep y'all, [00:15:00] there's so much work that we need to do. But this won't get better unless we understand the history of what we've been through.

And we start to change the story. The authors of this paper propose a few structural solutions to these. So to the problem of medical exceptionalism they propose making changes to education and training including reforms of the medical curriculum and the hidden curricula which will be more difficult because it is hidden.

Designing curriculum to empower students to better understand their rights and responsibilities in the clinical workspace. So, um, I'm all for that implementing workload reduction and duty hour restrictions while ensuring that physicians are adequately supported by other members of healthcare and hospital administrative teams.

 Those of us who are past training I have to go back and almost retrain ourselves to work in a healthier way, but the [00:16:00] real change will come. When we stop training physicians in the way that they've been trained, you know, for a hundred years. So the the structural solutions they propose for the medicalization of mental illness and burnout and physicians is eliminating stigmatizing language in physician licensing to make sure that people with a history of mental illness, aren't discriminated against providing tailored and dedicated mental health support as part of the occupational health services of hospitals and other healthcare institutions.

And I think that things that we can do to support that are to talk about when we get help. You know, like I've, I've had therapy and coaching, and those are things I continue to need on a regular basis. I think that is part of you know, we've talked about before, how being a physician is like being an elite athlete with a really long career.

Athletes have coaches, every single one of them. They don't only [00:17:00] have themselves. They're not a team of one, and I believe that physicians need that level of support so that we can maintain our physical and emotional health and be able to continue to be effective physicians and live happy and flourishing lives.

 I had an opportunity to hear Corey Feist, who is the brother-in-law of Dr. Lorna Breen whom the Lorna Breen act was named after I heard him speak back in January and he talked about His sister-in-laws struggle. Going back to work after having COVID, she contracted, COVID kind of earned early in the pandemic.

And Dr. Breen was the director of the emergency department at her large hospital. And she was experiencing some of the cognitive symptoms that many people have had after COVID and she went back to work and she was finding it very difficult to keep up mentally and she became. Terrified [00:18:00] that she would get fired or her license would be revoked.

If, if anybody found out just tragically. Um, even though her family helped her to get help, she committed suicide. And Mr. Feist talked about the fact that all, but one state's medical licensure board have questions on their licensure, paperwork about mental health that are intrusive. And I'll tell you, it's Mississippi is the one that doesn't have it.

I practice in Mississippi and I'm very proud of our state board of medical licensure because they've recognized that it's not relevant to ask a question other than do you have. A mental illness that impairs your ability to work as a physician. Just like we might ask a question about a physical impairment. Aside from that, there are also hospital credentialing and medical malpractice, credentialing questions about [00:19:00] about mental illness.

I got one, this was my malpractice company. I noticed it. I don't know if it was there before, and I just had noticed it for the first time, but there was a question just about, have you gotten psychotherapy? And I was like, what is this for? This is discouraging physicians from seeking care because they're afraid that if they have to say they have psychotherapy that they're not going to get malpractice insurance.

And there were other similar questions that show up on other credentialing. So. The Lorna Breen foundation and the healthcare heroes that has grown out of that part of their mission is to eliminate those questions a campaign to change credentialing and licensing requirements to only have the most relevant questions about mental health to keep from making physicians feel like they, they can't seek.

So then the next one, the individual responsibility. [00:20:00] Issue the authors of this paper their suggested structural solutions for that included implementing interventions to shift responsibility from individual physicians to institutions and systems. So looking into the institutional causes and then correcting those and also elevating workplace conditions to an institutional and system level responsibility, prioritizing improved physician wellbeing.

Just as highly as the quality of care and the patient experience because happy physicians, healthy physicians provide better care. 

So like I've said already, we have work to do inside ourselves, but we also have work to do together and work to do in our medical training environments and in our institutions. And it's not going to be easy. And I certainly don't have all the answers, but I have the energy and motivation to work on it, along [00:21:00] with you.

So in the spirit of that, I want to invite you to join me in a private Facebook group. So I will. Ask questions to verify that you're a physician you don't have to be someone who identifies as a woman. but it will be called women physicians flourish. We'll have a private Facebook group.

If you are on my mailing list, if you are on my email list and you occasionally get emails from me, I'm going to send you a link to join. I'm also going to put a link to join the Facebook group in some social media posts this week. So if you follow me on LinkedIn or Instagram or Facebook you can look there or if you'd like, you can look up.

 In the show notes, there's a link to my website, my podcast website, it's Rebecca Lauderdale md.com/podcast. And there's a place on there. If you'll kind of scroll to the [00:22:00] bottom of the page, where it says where you can enter your email address and I'll send you a copy of a little short book that I wrote about burnout, about the things that really helped me. Um, the women whose work made a big impact for me when I was burned out. So I'll send you that and I'll put you on my email list and I'll send an email out with the link to the Facebook group. What I'm hoping will happen there is that we can have some real honest 

productive conversations about specific interventions. We can share things we've done that have worked things that didn't work. Anyone who is having specific problems and is looking for solutions. Again, I don't have all the solutions, but I do have a large repository of articles and access to people who, who do have great ideas.

And so I love to talk there about ways that we can, [00:23:00] design better systems and also personally ways that we can improve. Our mindset improve the ways that we value ourselves and our behaviors. Sometimes just having other people say, yeah, it's okay to do that makes all the difference in the world. And so I want to be there to support you and.

We'll be able to support each other there. I hope that you will consider joining me in that Facebook group. We'll call it women physicians flourish. Please join me there.

And we'll keep talking, and we'll share victories and we'll share mistakes. That's another really important part of this self-valuation is for everybody to understand that we all make mistakes too. It's just part of being human.

So I'm going to talk more over the next couple of episodes about the culture of medicine and how we can turn the tide. So stay tuned, please. Give me a follow [00:24:00] on social media, reach out, send me DMS. I love to hear feedback from you. I am here because I believe that we can change medicine and I believe that we can all live flourishing lives. I spent a long time believing it was impossible, but I believe it now. And so I wanna, I want to infect you with that belief if you don't already have it. So come on over to the Facebook group and, uh, I hope to see you there soon, and I'll talk to you next week.

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