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 Table of Contents  
GUEST EDITORIAL
Year : 2021  |  Volume : 37  |  Issue : 2  |  Page : 139-142

The culture of medicine and students' wellness


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Submission22-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Dr. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_186_21

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How to cite this article:
Sharan P, Hans G. The culture of medicine and students' wellness. Indian J Soc Psychiatry 2021;37:139-42

How to cite this URL:
Sharan P, Hans G. The culture of medicine and students' wellness. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Oct 28];37:139-42. Available from: https://www.indjsp.org/text.asp?2021/37/2/139/320169




  Introduction Top


Reality is shaped over time by structures such as social, political, cultural, economic, ethnic, and gender constructs. Social reality is mediated through discourses that regulate what can or cannot be said, who has the authority to speak, who must listen and obey, and whose social constructions and experiences are valid or invalid.[1] These “truths” sometimes need to be challenged.

The tragic loss of young trainees to suicide, the recent attention to workplace harassment, and reports describing poorer than expected mental health of medical students and resident doctors point to the need for a review of our current medical culture.

For residents, modern hospitals have become difficult environments. Work profiles involve unrealistic work hours, unscheduled emergency work, disproportionate criticism, and toxic blame culture.[2] Residents are expected to balance learning, patient care, teaching, and documentation while working 12-h-plus days for months on end.[3] For students, the pressure to get postgraduation seats while laboring under increasingly demanding competency goals and curricula subverted in the face of specialty/super-specialty training needs, has led to a situation where explicit curriculum work is being undertaken during extracurricular time.

Impossible goals and dwindling resources produce academic/work-related emotional stress, which risks trainee and patient welfare. When life events related to physical or mental health, relationships, or family occur, there is little flexibility in the system to allow medical students and resident doctors to attend to their needs.


  Culture Top


Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they become implicit.[4] The culture of medicine can at the same time evoke images of benevolent individuals offering themselves in service of the sick and vulnerable and images of an institution marred by elitism and the abuse of power.[5] There are at least three levels to culture: artifacts (or symbols) – the visible manifestations of culture (e.g., our actions ad heroes), espoused values – what we claim as our values and priorities (e.g., codes and mission statements), and tacit assumptions – the underlying things we truly believe and value (e.g., altruism and obedience).[6]

Even when the larger culture does many things well, problems with culture can arise with its subcomponents.[3],[4] Incongruity between artifacts and espoused values are giveaways of problems related to cultural subcomponents. Some incongruities that affect trainees and their well-being are listed in [Box 1].



These incongruities between stated values and institutional behavior give mixed messages to trainees and create cognitive dissonance regarding the institution's training goals and the stated aims of the profession.[3],[4]


  The Need to Change the Culture of Medicine Top


Many studies indicate that the prevalence of emotional distress, burnout, and suicidal behavior among residents is dramatically higher than that in the general working population, and has both personal and professional implications.[7] Recognizing the importance of this problem, several organizations have started addressing this issue. These efforts have mostly focused on efforts to help physicians strengthen personal resilience skills and occasionally on organizational changes, for example, redesigning workflows and enhancing teamwork.[7] Although these efforts are useful, they do not address some of the fundamental cultural issues underlying this problem.[4] Some fundamental cultural issues that cannot be addressed by technocratic solutions are outlined in [Box 2] and [Box 3].



The National Academies of Sciences, Engineering, and Medicine (2018) identified five factors to be associated with sexual harassment in medicine: (1) perceived tolerance for sexual harassment, (2) male-dominated work settings, (3) hierarchical power structure, (4) symbolic compliance policies and procedures, and (5) uninformed leadership. It is evident that strategies such as mentorship/sponsorship cannot by themselves mitigate these issues that are related to institutional and training cultures.[24]


  Bringing about Change in Medical Culture Top


The modifiable and toxic aspects of working as a doctor must be addressed and a new culture formed that promotes a nurturing and supportive approach to teaching and supervision and a medical practice that facilitates well-being, quality of life, and sustainable medical careers.

Many natural elements of medicine's culture (e.g., altruism – providing quality care to patients, compassion-supporting colleagues, nonstigmatizing attitudes, objectivity, and value for evidence) support the change process. However, there is also much resistance to change.[4] The resistance to change is articulated through minimization/denial of the problem, defending tradition (change will lower standards, or make physicians in training unfit for real-world situations), highlighting practical difficulties (lack of resources), or appeals to higher virtues (need to uphold higher standards).

Culture change involves unlearning some old habits and ways of thinking and incorporating new ones.[4] For a dimension of culture to change, it is necessary for leaders to be convinced that a change is necessary. Thus, steering committees should incorporate senior representatives of the organization and stakeholder groups.

Some ways to facilitate culture change related to trainees' well-being are listed in [Box 4].



Pilot studies, phased initiatives, or empowering one department or group to develop and test an alternative method before scaling it up may be useful to facilitate the learning of new approaches.[4]


  Conclusions Top


If we are going to make substantive progress in addressing many of the problems facing our medical training system and the high prevalence of mental ill-health among our trainees, we must recognize the cultural dimensions to these challenges. This will require an honest appraisal and new dialog at the level of our profession, our educational institutions, and the health-care delivery system.

We call upon all medical professionals to reflect more deeply on the cultural values of medicine to facilitate the propagation of values we wish the medical profession to embody.[5]



 
  References Top

1.
Paradis E, Nimmon L, Wondimagegn D, Whitehead CR. Critical theory: Broadening our thinking to explore the structural factors at play in health professions education. Acad Med 2020;95:842-5.  Back to cited text no. 1
    
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Brown C, Egan RJ, Lewis W. The hidden curriculum: Requiem for a surgical dream. Postgrad Med J 2019;95:237-9.  Back to cited text no. 2
    
3.
Meeks LM, Ramsey J, Lyons M, Spencer AL, Lee WW. Wellness and work: Mixed messages in residency training. J Gen Intern Med 2019;34:1352-5.  Back to cited text no. 3
    
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Shanafelt TD, Schein E, Minor LB, Trockel M, Schein P, Kirch D. Healing the professional culture of medicine. Mayo Clin Proc 2019;94:1556-66.  Back to cited text no. 4
    
5.
Michalska-Smith M. Describing a culture from within. AMA J Ethics 2015;17:108-10.  Back to cited text no. 5
    
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Schein EH, Schein PA. Corporate Culture Survival Guide. 3rd ed. Hoboken, NJ: John Wiley and Sons, Inc.; 2019.  Back to cited text no. 6
    
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Dyrbye LN, Shanafelt TD. Commentary: Medical student distress: A call to action. Acad Med 2011;86:801-3.  Back to cited text no. 7
    
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Romero R, Miotto K, Casillas A, Sanford J. Understanding the experiences of first-generation medical students: Implications for a diverse physician workforce. Acad Psychiatry 2020;44:467-70.  Back to cited text no. 8
    
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Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, et al. Estimating implicit and explicit gender bias among health care professionals and surgeons. JAMA Netw Open 2019;2:e196545.  Back to cited text no. 9
    
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Dahlke AR, Johnson JK, Greenberg CC, Love R, Kreutzer L, Hewitt DB, et al. Gender differences in utilization of duty-hour regulations, aspects of burnout, and psychological well-being among general surgery residents in the United States. Ann Surg 2018;268:204-11.  Back to cited text no. 10
    
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Elmore LC, Jeffe DB, Jin L, Awad MM, Turnbull IR. National survey of burnout among US general surgery residents. J Am Coll Surg 2016;223:440-51.  Back to cited text no. 11
    
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Stephens EH, Heisler CA, Temkin SM, Miller P. The current status of women in surgery: How to affect the future. JAMA Surg 2020;155:876-85.  Back to cited text no. 12
    
13.
Altieri MS, Salles A, Bevilacqua LA, Brunt LM, Mellinger JD, Gooch JC, et al. Perceptions of surgery residents about parental leave during training. JAMA Surg 2019;154:952-8.  Back to cited text no. 13
    
14.
Gifford E, Galante J, Kaji AH, Nguyen V, Nelson MT, Sidwell RA, et al. Factors associated with general surgery residents' desire to leave residency programs: A multi-institutional study. JAMA Surg 2014;149:948-53.  Back to cited text no. 14
    
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Gray K, Neville A, Kaji AH, Wolfe M, Calhoun K, Amersi F, et al. Career goals, salary expectations, and salary negotiation among male and female general surgery residents. JAMA Surg 2019;154:1023-9.  Back to cited text no. 15
    
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Oldfield K. Humble and hopeful: Welcoming first-generation poor and working-class students to college. About Campus 2007;11:2-12.  Back to cited text no. 16
    
17.
Grbic D, Sondheimer H. Personal well-being among medical students: Findings from an AAMC pilot survey. Assoc Am Med Coll 2014;14:1-2.  Back to cited text no. 17
    
18.
Mason HR, Winseman J, Marcellon R, Huamantla M, Ruiz C, Ayala EE. First-generation medical student wellness in the United States: A cross-sectional snapshot. J Best Pract Health Prof Divers 2018;11:96-106.  Back to cited text no. 18
    
19.
Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, et al. Harassment and discrimination in medical training: A systematic review and meta-analysis. Acad Med 2014;89:817-27.  Back to cited text no. 19
    
20.
Fitzgerald CA, Smith RN, Luo-Owen X, Turay D, Ferrada P, Han J, et al. Screening for harassment, abuse, and discrimination among surgery residents: An EAST multicenter trial. Am Surg 2019;85:456-61.  Back to cited text no. 20
    
21.
New Zealand Resident Doctors' Association. “Workplace Bullying: A guide for resident doctors/first-year house officers”. 2009. http://www.nzrda.org.nz/wp-content/uploads/WORKPLACE-BULLYING.pdf.  Back to cited text no. 21
    
22.
Leisy HB, Ahmad M. Altering workplace attitudes for resident education (A.W.A.R.E.): Discovering solutions for medical resident bullying through literature review. BMC Med Educ 2016;16:127.  Back to cited text no. 22
    
23.
Bairy KL, Thirumalaikolundusubramanian P, Sivagnanam G, Saraswathi S, Sachidananda A, Shalini A. Bullying among trainee doctors in southern India: A questionnaire study. J Postgrad Med 2007;53:87-90, 90A-91.  Back to cited text no. 23
    
24.
Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that Undermine a Culture of Safety; 2008. Available from: http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/. [Last accessed on 2021 Jun 22]. The National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture and Consequences in Academic Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2018.  Back to cited text no. 24
    




 

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