Indian Journal of Social Psychiatry

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

The culture of medicine and students' wellness


Pratap Sharan, Gagan Hans 
 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Dr. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
India




How to cite this article:
Sharan P, Hans G. The culture of medicine and students' wellness.Indian J Soc Psychiatry 2021;37:139-142


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 Sep 21 ];37:139-142
Available from: https://www.indjsp.org/text.asp?2021/37/2/139/320169


Full Text



 Introduction



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



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].[INLINE: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



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].[INLINE:2][INLINE: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



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].[INLINE: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



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]

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