Medscape is a Web Site that provides services to physicians and health care providers. It coalesces articles, provides a CME portal, and is a site for original content. In an article yesterday entitled THE WHITE COAT DIDN’T FIT. Narjust Duma MD describes her life as she came to the United States after graduating from medical school in Venezuela. She completed a difficult and apparently very competitive residency in Internal Medicine at Rutgers and then was accepted and completed a Fellowship in Medical Oncology from the Mayo Clinic.
As she tells her story during the course of her clinical transition to becoming a physician, she also had to redefine her identity as a woman and a person. “I had used all my energy trying to be someone I was not”. As she proceeded through internship and residency and then fellowship she also dove down the rat hole of mental illness. In her story, she relates that being in a foreign country and being treated differently because she was not a Native American was the primary reason for her identity crises. But the strain of long hours, the competition for future advancement in programs and for Fellowships, the care of patients and many times for many young physicians realizing that failure is part of the game, are all reasons for young people to have feelings of a “lack of self-worth”.
Having gone through 7 years of medical and surgical residency myself, and later on being responsible for the training of younger surgeons I have watched as they have evolved, confronted their own shortcomings, redefined themselves as clinicians and yes even developed into new, different, and most but not all of the time better people. Today many surgical and medical residencies require annual psychiatric evaluations—much like pilots and Special Forces operations specialists are required to undergo. We didn’t have this in my day, but like many surgeons, I still have flashbacks and nightmares about events from over 40 years ago. Because training was difficult doesn’t mean it was bad. Most of it was necessary, Integration of foreign doctors into a new system of medicine and a new culture is only one of the many challenges that need to be faced as they go through their training. But I honestly believe that it is much less of a challenge than the other daily obstacles that have to be overcome.
As a teacher of doctors, I wanted to see how they reacted to these challenges while they were still under the supervision of attending physicians who could mentor them and keep them from making mistakes that could negatively impact their patients and families. Lack of sleep, constant testing, and requirements for laboratory projects all kept our feet to the fire. Rounding everyday a 5AM and then late at night forces everyone to change— keep your head down.
The American Health Care System relies very much on training doctors under demanding conditions so that when they leave “THE U” they can know themselves that whatever challenges they may face, they have within themselves the ability and the insight to figure out how to take care of a complication, or an impossible patient. At least that is the way it used to be. Today many young surgeons and physicians are graduating from residencies feeling unprepared to be on their own. They pursue fellowships or extra years of mentoring. I believe that the reason for this is because residencies are becoming too easy but certainly not in all cases.
Another big change in Medicine is our dependence on foreign medical school graduates. According to a Review by The Association of American Medical Colleges 56% of Medical school graduates are White, 18% are of Asian descent, 6% are Hispanic and 5% are Black. 23% of medical residents in the United States today are foreign born. The percentage of these doctors by race is in line with the overall residency numbers.
I did my pediatric trauma surgical training at the University of Florida under Dr. Joe Tepas who is now deceased. He was a great teacher and a role model. His residency and Fellowship programs were populated almost entirely by young doctors of Cuban American descent. Several years before his passing I asked him about this and he told me in a jocular manner that he always liked to hire foreign students and people who were dyslexic because they always worked hard to out work each other and they always wanted to please. A sick joke by today’s politically correct standards, but truthful. During my time at Florida, these guys and gals worked their fannies off and I could never rest competing against them. They made me better just like they made Dr. Tepas’s program better. I always breathed a sigh of relief whenever my service was cross matched with an Ivy League snowflake who grew up in the suburbs.
So one of the nice things about Medscape articles is that physicians can respond. I was happily surprised to see many posts from physicians and surgeons, who were immigrants themselves or foreign-born medical school graduates who very much disagreed with the premise of Dr. Dumas’s article—”being foreign born made me an outsider and I had to change my personality”. A urologist opined that though he was sympathetic to her depression a clinical diagnosis that he was given during his residency, the feeling of being in a strange world with strange heavy demands had nothing to do with her immigration status. He pointed out that both her mother and father in Venezuela were physicians and one was on the teaching faculty. He also pointed out that language had never been a barrier to her as it had been for other foreign medical school grads. Finally, an older immigrant physician—40 years ago the bar was set much higher for foreign grads than it is today, simply said—”just be better”. I worked for many years on the Trauma service at St. Al’s with the 1st woman trauma surgeon in Idaho. She trained in the military at a time when she was the only woman in her residency. Talk about isolation. Talk about tough. Talk about rising to the occasion and being the best. She made me better because she “had to be better” Thanks Renee.
The problem of mental illness in residency should not be confused with problems of assimilation and “fitting into a culture” no matter if one is an immigrant or not. Mental illness is a real problem in all the medical professions and in society. Life is hard. We all need the helping hand of others sooner or later. Dr. Dumas’s dive was exacerbated by pills given to her with the wrong diagnosis. By identifying the cause of her depression and deploying mitigation strategies that have been now used for years to attend to the side effects of residency—cultural isolation is just one trigger, then the real reason for her “lost sense of value” could have been addressed.
My own dive down the hole occurred my 5th year of residency after I attended to a Navy pilot who had crashed landed his plane on an Aircraft Carrier 90 miles out to sea. Mike Foster had been my boyhood friend growing up in Columbus Ohio. After his 4th operation, I thought Mike was going to die—but he survived. Many years later I saw Mike again and he told me that during that time he not only prayed for his survival, but he prayed for me. If we all believe in God’s infinite mercy, and we believe that we are all created in His image, then no matter the challenges that are set before us or that are in our past, then we should understand that we are worthy of His love—and also our own. Maybe if more people understood that and practiced that, there would be much less mental illness. It also sure helps to have other people praying for you.
It is easy to blame an “ism” for a problem. Racism, sexism, homophobia, xenophobia—you name it. All are problems. All need to be confronted for what they are—on the spot by each one us in real time—not by government. None are an excuse for failure. None are an excuse for victimhood. A wise man once told me that the only person that can make you feel bad about yourself (unworthy) IS YOU.
MAGA “Fight Like Hell”