Harvard Medical School recently held a symposium on learning. The topic of the meeting was “Resiliency and Learning: Implications for Teaching Medical Students and Residents.”
Chronic stress, as experienced by physicians, affects the endocrine and other systems causing immune suppression and metabolic disorders leading to depression, cognitive dysfunction and a lot of other bad things. Similar stress follows in the wake of natural disasters, war and severe abuse (again, pertinent to the practice of medicine).
The researchers found that these problems can be avoided or reversed by training as that undergone by so-called “stress-hardy groups” like the Navy SEALS. The qualities that help make Navy SEALS resilient are “a social support network, [o]ptimism (including faith in a higher cause or power), perseverance (work ethic), responsibility and integrity…”
Medical students and physicians can be taught to be resilient resulting in decreased rates of depression and burnout.
Makes sense to me. Let’s train doctors in the manner of Navy SEALS.
But wait. Not mentioned in the Harvard Medical School Focus article is an important feature of the Navy SEAL culture—Navy SEALS do not work 16 hours per day or 80 hours per week. A major part of their training is centered on performing at a high level even when sleep-deprived.
Navy SEAL Hell Week is described as follows: “In this grueling five-and-a-half day stretch, each candidate sleeps only four total hours but runs more than 200 miles and does physical training for more than 20 hours per day. Hell Week finds those candidates who have the commitment and dedication required of a SEAL. Hell Week is the ultimate test of a man's will and the class's teamwork.” It sounds a lot like a surgical residency training program circa 1972.
Although often skeptical when it comes to research from Harvard, I am all for this. We need to institute Navy SEAL style training for all residents and medical students. Let’s start by making them more resilient. No going home the day after call. No limits on work hours. Let’s do some cases! “OOHRAH!”
[Thanks to Bill Cadigan of the blog “Doctor Parking Only” for tweeting a link to the story.]
39 comments:
You do realize that Hell Week lasts for...a week, while residency lasts 5 years, right?
I know that Hell Week is only a week but SEALs practice going without sleep all the time, even after their initial training. And, residency training is not nearly as rigorous as SEAL training.
As I pointed out in a previous post (http://is.gd/GKn3bR):
"Here is a little known fact that many people conveniently overlook when discussing resident working conditions. A resident who is on call for 28 consecutive hours may not necessarily be awake for all of that time. Some nights are not busy. There can be time for napping. This type of work is not analogous to long-distance bus driving or piloting an airliner both of which require long hours of uninterrupted, monotonous work."
Yep. I've written about this, too, many times. Like this, in which I recommend not getting sick, or, if you do, treating it with gin and a hose attached to the tailpipe.
I really hope you read the article. I think the main point can be summarized at the very end.
Quoted "Resilience can be taught, said Everly, who also directs the Resiliency Sciences Institutes at the University of Maryland. First, let people experience success: Assign them to a successful group. Second, create a surveillance system and safety net, and provide encouragement, mentoring and training. Finally, mitigate the impact of stress by promoting “self-efficacy”—the belief that we are agents of change. Everly noted, however, that one cannot “give” self-esteem; it must be earned through personal accomplishment in the face of a challenge. Calling for a cultural shift, he said, “We must reframe mistakes as opportunities for learning.”"
I don't think anywhere in the article did it mention that residents should be trained like navy seals by making it HELL for them. No post-call days, no work hour limits, train people by sleep depriving them?
If you want to train residents to be more resilient, I think the carrot will work much better than the stick.
What medaholic said. Residency is not a contest about who is tougher. It is about learning how to take care of patients. You sound like you have a giant masculinity problem.
@medaholic and Old MD Girl,
I didn't bring this up. Experts from Harvard did. They just left out the part about learning to handle stress by actually experiencing it when you are tired.
"We must reframe mistakes as opportunities for learning." is a nice sentiment. Please Google "Seattle nurse suicide" to see how well the "culture shift" is working out. So much for "Just Culture," which does not exist anywhere in medicine. I do agree that one cannot give self-esteem.
I don't understand your reference to "a contest about who is tougher." I never said anything like that.
"Please Google "Seattle nurse suicide" to see how well the "culture shift" is working out."
The utter incompetence of your generation -- killing tens of thousands of patients every year with preventable errors secondary to the irrational systems, sloppily maintained, that you and your colleagues built up and managed.
Not to be blunt, but maybe while we're stuggling to clean up your mess and catch up with the rest of the developed world, you could forgo your attempts to shift blame with anecdotes?
@TheTracker
I appreciate the comment but must disagree with some of it. The punitive culture is real. The story of Seattle nurse who committed suicide is an illustration of why changes need to be made, not an attempt to shift blame. Read about it.
@TheTracker
Here's news of the rest of the developed world. Despite their wonderful system and short duty hours, it seems that 5000 are injured and killed in the UK every 6 months. http://www.guardian.co.uk/society/2011/sep/13/5000-dead-injured-nhs-safety-blunders?CMP=twt_gu
The attrition rate in the training program to enter the Navy SEALs is around 80-90%, meaning that of the motivated, healthy, fit group of young men entering the training course only about 10-20% are able to tolerate it and successfully become Navy SEALs. The SEALs are extremely resilient in part because they are an elite group where the less resilient have been weeded out. Do you think an 80% attrition rate in medical training is acceptable?
Obviously, an attrition rate of 80% is impractical. I never advocated that. However, the attrition rate for surgical residents may already be as high as 20%. i believe that is due to the fact that med students are coddled and have no idea what a surgical residency involves. They figure that it will be easy now that work hours are limited. It isn't so.
Residency is not as physically or mentally as demanding as SEAL training, nor should it be. I simply agree with the Harvard research that says residents should be trained to be more resilient.
PS: I was exaggerating in the last paragraph. The establishment never listened to me when I was a program director. I doubt they would listen now.
Your last word should be "HOOYAH". "OOHRAH" is what Marines say.
If you say so, it must be true. After all, you are anonymous. They sound quite similar, if not exactly the same to me.
I know because I've seen movies.
Interesting concept. I'm not sure that Navy Seals have the same set of skills required to be a caring, compassionate surgeon. I finished my surgical training two years ago. I had many sleepless nights, and am handling solo practice just fine. I also get much more sleep now than during my residency. I think we are taught resiliency - quite well, in fact. Those who don't, drop out and go into anesthesia.
And unlike many surgeons that went before us: we also have fun personalities, successful marriages and children we know and love. Imagine that. You don't want to train surgical robots. You want resilient, compassionate, ethical, skilled clinicians.
jbean, thanks for reading and commenting. Now that this post is almost a year old, I have a confession to make. I was not really serious when I wrote this. I was exaggerating to make a point.
I'm not sure if there are any data to support your apparent contention that younger, more gently trained surgeons have a lower divorce rate or better personalities than us Navy Seal trained surgeons.
I always figured the month I spent in 1973 at Camp Lejeune as a US Navy Corpsman learning field medical skills for posting with the Fleet Marine Forces was as close as I EVER wanted to BUDS or SERE - WORST MONTH OF MY LIFE - surgical residency with Nyhus and then Harken pre-limits was long and hard, but as far as I know no live ammo was involved.
Perhaps a program of that nature - one month - night exercises, all the BLS - ACLS - ATLS - PALS - NRP - whatever practical skills possible - grind you down and build you up...would be valuable. Outward Bound used to be that sort of program for the wayward youth back in the day, perhaps our medical students need that sort of exposure prior to selecting residency paths?
Interesting comment. Thanks. I agree it might be good, but don't look for it being implemented any time soon.
I love this. Completely agree.
Unknown, thanks for reading and the kind comment.
"Obviously, an attrition rate of 80% is impractical. I never advocated that. However, the attrition rate for surgical residents may already be as high as 20%."
Fair point......but this is precisely how evolution induces change. It wipes out and selects the survivors and then expands them. Mother Nature has been pretty successful and far more so than our profession. I wish we used evolutionary medicine to guide more of our clinical and surgical decisions and training. We might not be a species in decline.
john, thanks for the comment. The attrition rate of surgical residents is explained here. http://skepticalscalpel.blogspot.com/2012/06/why-is-attrition-rate-of-general.html
I'm a neurosurgeon so I know a bit about attrition rate......when i trained it was north of 20%. Now it's a country club.
Fascinating. I resigned as the Program Director at MGH (a Harvard Hospital) two years ago largely because the "system" would not allow the program to be as rigorous as it had been and should be. Clearly, the "system" did not agree with some of it's researchers. SkepticalScalpel has it right. Period.
Charles M. Ferguson
Charles, Thanks for the kind comment. I am happy that you read my blog and have taken the time to agree with me.
You might be surprised to know who I really am.
The current surgical education paradigm is a mutilated and politically correct form of the unending hell hole inefficient surgical residency of the good old times. If more time had been spent more time on actively working on evolving surgical education we may have been spared of a generation of surgeons who think they are prepared but actually may not be. I believe the deluge into specializations is partly because they feel they are underprepared after residency.
fella, I agree that many feel they are unprepared and that's why they take fellowships. There are many negative forces at work here. How would you have evolved surgical education?
I wish that the surgical curriculum is more stringently devised, uniformly executed and should be competency based and not allow for people to get through if they are just"okay at it". Competencies should be clearly defined and assessed even more strictly and without the need for political correctness. The absite and the board exam are point performance indicators and residencies are too variable in their interpretation and execution of the "syllabus".The object should be a good surgeon not 80 hours or 5 years for that matter.
This is my first year out in practice. When I have a better idea than this I will let you know.
Fella, I appreciate the comments. There is a plan to standardize the curriculum. The board and RRC can tell you what to teach, but a program is at the mercy of its faculty. Doctors are not necessarily good teachers.
There is also a lot of discussion about going to competency based training. There are several issues yet to be resolved though.
Just to nitpick (and FYI I love your blog), it's "hooyah" for the SEAL community. "Oorah" is the vernacular of the Marine Corps.
As for the actual training, I wholeheartedly agree with implementing (or reverting back to) this sort of mentality with regards to surgical training. I can definitely say that my prior training has helped me well while on the wards. Helps to know just how much more is left in the tank, how much more I can really put out before I have nothing left.
Plus, it just feels really awesome looking back after completing a particularly grueling task (whether it be a monster call, a pain forced march, or a long swim in cold ocean water). Some say it's a bit selfish or even egotistical, but it is awesome knowing you can do something like that.
~ Prior Navy, current medical student
Luis, thanks for chiming in. "Hooyah" and "oorah" sound the same to me, but I'll take your word for it.
I agree that conquering a challenge breeds confidence.
Hello, i am on my 7 night on call for 24 hours as a junior surgeon for monthly pay of 1000 usd in my country, is this tough or what ? :-) :-)
igor, it is tough. I'm guessing you are not in an EU country.
I get $500/month as a junior surgeon. As residents, we had what we called hell-weeks. Meant we were on-call for seven straight days, starting Saturday morning and ending next Saturday afternoon, 3pm. That was every 3rd or 5th week, depending on number of residents in the ward. I got no pay for the first 18 months. Every 4th Sunday we were on-call and we have Monday and Thursday calls. So Sunday and Monday stretch extended to 60 hours sometimes.
It was nuts.
But I learned.
And survived.
Now, they have easier schedules for residents and interns here. Shorter working hours. And lots of molly-coddling.
That has resulted in a reduction in efficacy and a lower standard of patient care.
What happened to us wasn't good. But what they are doing to the new guys is worse, throwing out substandard surgeons and doctors.
I always ask them one thing: would you be OK if you got into an accident and your treating doctor was someone like you. 9 out of ten, I don't get any response.
Surgery is less about luxury, and more about a certain mental toughness to get the job done, rest be damned, comfort be damned.
And when people start asking about that 31st day of the month, well, the PD probably didn't get the right people as his residents.
SEALs are self-motivated. Nobody wants to ring the bell.
Neither sould a surgery resident.
It's the highest calling, the best job in the world.
You have to WANT it to do it right.
Interesting take on the subject.
"I always ask them one thing: would you be OK if you got into an accident and your treating doctor was someone like you. 9 out of ten, I don't get any response."
Just a way to make them see that what they/we do matters.
A means to motivate in an environment that doesn't pay big $ even after one is qualified as a surgeon. Or for that matter, an environment that is in dire need of a paradigm shift when it comes to post-grad resident training and change of priorities when it comes to patients in order to compete and excel in a world of exceptional healthcare.
Young doctors are the future.
They need to be self-motivated and not just because of possible gains once they graduate from residency.
There's more to life than money.
Interesting take. BUDS training is highly controlled with constant, immediate supervision. You can't fart wrong without an instructor correcting you. Additionally, Navy SEALS in training are only responsible for their team. An equivalent example would be saying Residents are only responsible for other residents and not patients. The aviation community thought you could teach resiliency by working until exhaustion. But they ended up crashing airplanes. The fact is, and it's taught over and over in aviation safety school, a person does not perform at their peak and they miss things when they are severely sleep deprived. That is one of the lessons Hell Weak is suppose to teach. Safety policies are often derided because the results are hidden. It's not until after they are removed do you really see how effective they really are. The real question is, are residents getting the trading they truly need (not what one thinks they should have) under the current policies, keeping in mind ones ability to learn severely diminishes as one becomes sleep deprived.
Drew
Drew, I wouldn't expect anyone to have read all 36 comments above. Four years ago in response to someone who also thought I was nuts, I said this, "thanks for reading and commenting. Now that this post is almost a year old, I have a confession to make. I was not really serious when I wrote this. I was exaggerating to make a point."
HA! Well, you got me hook, line, and sinker. Safety nerds can be very gullible.
I just found your website and I've enjoyed reading it. I'm in the middle of a career change and am starting my second year of med school. I will be the first to admit I know very little about medicine and will defer to the judgement of the "gray hairs" of the industry. I do think my experience as military pilot and an airline pilot brings a perspective that can be useful when dealing with safety, and the topic does strike emotions in me due to needlessly losing a few good friends. I should guard against that more carefully until I get the experience needed in the industry.
I also liked the article you wrote about medical students needing a solid understanding of statistics. Having just finished what I consider the best statistics class I've had, it's nice to see you discuss the material she emphasized.
Drew
Drew, thanks for the kind words and for reading my blog posts.
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