As we enter the fourth month of the COVID-19 crisis, stories of heroism from the frontlines of this global effort have been steadily forthcoming.
The first and most famous was the tale of Li Wenliang, the 34-year-old ophthalmologist on staff at Wuhan Central Hospital. His advisory to colleagues on a private WeChat forum that a new SARS-like illness may have emerged and that they should prepare their families and friends eventually leaked to the global community. The alarm raised by Dr. Wenliang’s accidental call to action won him an official admonishment from the Chinese government for “making false comments on the internet.”
After his passing on February 7 from COVID-19, the Chinese government rescinded the official admonishment and apologized to the late Dr. Wenliang’s family. The people of the world are indebted to Dr. Wenliang’s commitment to public awareness of the truth.
Miles away in Italy, the hardest hit European country to date, medical students are being fast-tracked into physicianhood nearly a year early. This quasi-conscription will free up seasoned outpatient providers who are desperately needed in emergency rooms and ICUs throughout that nation.
In times of crisis, we expect heroics of this sort from our physicians and physicians-in-training. As Canon Brodar wrote in his recent in-Training piece calling for medical students to be allowed to train during this crisis, physicianhood, like the priesthood, is still considered a vocation by many: a profession whose practitioners are “called” to the work by a higher sense of moral purpose, if not by God himself (“vocation” from the Latin “vocatio” meaning “to be called or summoned”). This distinguishes health care workers from the vast majority of the modern American workforce, who wouldn’t (or, at least, shouldn’t) claim that their labor upholds a moral or religious obligation.
Our calling to care for the sick and suffering, regardless of their station or health status, is the moral engine that animates every inch of the American health care system. It is responsible for the everyday extraordinary actions of modern physicians. When our doctors stay hours after their shifts to see our sick children, when they spend days navigating byzantine insurance roadblocks to get us the right medications, or when they waive their fees when we lose a job or are just having a hard month, patients attribute these acts of kindness to the physician’s moral calling to serve.
However, the world looks much different from the physician’s perspective. What to a patient seems like an inspired act of good will is to the modern American physician an objective necessity of their work environment. Physicians and physicians-in-training go out of our way to provide care for patients not because we are better than anyone else or we feel duty-bound by a strict moral code, but rather because we work in a system more dysfunctional than almost any other in America. So broken is the American medical system that without health care workers’ myriad small acts of inspired good will, American patients simply wouldn’t receive the ordinary, much less extraordinary, care they deserve.
During my first two years of medical school, I was trained in medical ethics just like all my peers, but I was also trained to recognize and respond to the social determinants of health that color so many of the medical problems our patients face. I was trained such that it is my duty to address the patient’s COPD and their experiences of racism, poverty, housing insecurity and insurance status as it pertains to their health (which it always does). It is not enough to attend to a patient’s biological pathophysiology; it is the interplay of biological, psychological, social, economic and political pathology that creates the symptoms and syndromes physicians treat.
I entered my clinical rotation year eager to bring this holistic view of medicine to bear on the patients I would have the privilege of working with. That all changed within the first month when I saw nearly as much suffering walking the halls as I saw in the hospital beds. The eyes of every provider were bruised by sleeplessness and fatigue. Providers called on the dark arts of gallows humor to alleviate their guilt for never seeing their husbands, wives, and children (“I bet I see my children even less than you do,” I once heard one physician facetiously brag to another). One sees numerous “near-misses” and occasionally even a fatal error, unsurprising considering just how many patients doctors are asked to manage simultaneously. In fact, medical errors account for approximately 250,000 deaths each year, third behind heart disease and cancer.
In quieter, more inspired moments, my fellow providers would reiterate their own moral commitment to the holistic approach to medicine I was hoping to emulate as a student-physician. When we re-entered the fray after a quick lunch or spot of coffee, however, the stark realities of the practice of modern American medicine left little room for the exercise of morally-informed medicine. Are we upholding our moral duty to the patient when circumstances force us to discharge a homeless patient with diabetic ulcers and heart failure back to the street? How about when we prescribe a necessary medication that the patient’s insurance won’t cover, leaving them to choose between life-saving medication and feeding their children? I hadn’t expected that training as a physician would be nothing less than a trek through an endless moral minefield. After a few months on rotation I came to see cynicism and gallows humor as the scars of prolonged moral injury.
Medical students can’t truly appreciate the bio-psycho-social toll that working in such dysfunction has on providers until they see it for themselves. The suffering among the licensed physicians was only half the story. As my clerkship year progressed, I witnessed my fellow classmates begin to take on the ego defensives of their higher-ups. The moral callouses showed more on some than on others, though everyone, including me, was forced to build up something of a thicker skin. Many people began dissociating to ease their suffering; others went for medication and therapy. No matter the method, all of us changed during that year on the wards — some of us into people we had a hard time coming to terms with.
Having for the first time seen medicine for what it truly is and seeing how it affects its practitioners, I decided to take a year to study provider mental health and wellbeing and to help my school build up its student mental health infrastructure. In that time I came to understand that the failings of modern American medicine are best represented by the mental health crisis playing out in chart rooms across the country. The numbers are a tragedy.
According to one meta-analysis, American male physicians experience suicide at a rate 1.41 times that of the general population; female physicians, at a rate 2.27 times the national average. A retrospective analysis of resident physician deaths between 2000 and 2014 showed that overall, only cancer accounted for more resident physician deaths than suicide; among male residents, suicide was the most common cause of death. The prevalence of substance and alcohol use disorder, depression, anxiety and burnout among physicians far exceeds those of most other professions. On the whole, the American medical workforce is woefully unwell, thanks in large part to the fact that the moral center of American medicine has been under siege for decades.
So, as someone who’s studied the moral, mental, physical and social havoc the modern American medical system wreaks on trainees and providers, Mr. Brodar’s invocation of the moral duty is not the clarion call to action he believes it to be. To the trained ear, his call is an uncritical recitation of the ethical stance that, in our modern professional environment, has left providers vulnerable to injuries of all sorts.
Still, there are several reasons why I’m uneasy offering criticism of Mr. Brodar’s position. First, his position is often taught in medical schools across the country, leaving those of us who disagree with the common stance of feeling isolated and vulnerable as we enter the next phase of our career. Second, we are in a moment that truly requires medical heroics. Offering criticism of his position in the age of COVID-19 appears, at first glance, to be poorly timed. Third, and the most personal, I have always felt compelled by duty and have, on several occasions, “run toward the fire” as Mr. Brodar says we physicians are trained to do. To argue against him feels like disparaging my better nature.
Nonetheless, times of crisis peel back indifference and defenses to expose the true nature of things. The true nature of modern American medicine is that its practitioners were suffering though a mental and moral epidemic before the novel coronavirus ever arose. So when Mr. Brodar calls on students to “run toward the fire,” he is encouraging them to run along a moral path so littered with hazards as to almost guarantee an injurious end, just as it has for many of those who have come before today’s medical students. This type of uncritical absorption of expired ideals must not be passed onto the next generation of physicians whose job it will be to mend the moral mess we’ve inherited.
What’s more, Mr. Brodar’s evangelical adherence to the simplistic ethical dictates of our profession creates the conditions for confirmation bias on display in his own work. Yes, as Mr. Brodar noted, perhaps only 3.8% of Chinese health care workers contracted the virus, and perhaps the younger faired better than their older counterparts, but how many lives were impacted by those 3.8% becoming sick? 3.8% of the NBA becoming sick doesn’t matter but to the players and their families; 3.8% of the health care workforce becoming sick would have a tremendously negative impact.
This is before we even consider all the workers who would be forced to self-isolate when they find out their co-worker has been compromised by infection. The chance that a medical student could bring community-acquired COVID-19 into the hospital or outpatient clinic is too high a cost to justify continued learning, at least until we have better control of the current outbreak. Student utilization of precious personal protective equipment in a quickly worsening national shortage that’s so bad citizens with sewing skills are being called upon to make medical masks is another cost to consider. How about the straightforward fact that medical student education draws time and effort away from patient care?
Do the potential benefits to medical student education justify all these grave risks to patient and provider health? Maybe, maybe not (likely not). Without a full rendering of the problem, there is no reason to have confidence in Mr. Brodar’s simple moral arithmetic when more complex math is called for. In his zeal, Mr. Brodar has failed to show that medical student participation in this crisis would uphold the paramount ethical principle of medicine: first, do no harm.
However, if things turn for the worse, as they did in Italy, the expertise of advanced trainees may be called upon. When called upon we will go because, at that point, it will be clear that our presence in the workforce provides a net benefit to all involved.
Though I disagree with Mr. Brodar’s methods and conclusions on this issue, I do agree that this is an inflection point for modern American medicine. Our profession has been working at the breaking point for years, the costs of which have manifested as a mental health epidemic among our cherished providers and mentors. Only widespread heroism will keep our medical system from breaking under the weight of the COVID-19 crisis.
But when this chapter in medical history closes, it will be time for the next generation of providers to assume control over what is left. It will be up to us to build a medical system that doesn’t rely on heroics for everyday functionality. Preparing ourselves for that responsibility is much more important, and much more difficult, than learning the specifics of providing care amidst chaos, especially when our presence could do more harm than good. If we’re going to rise to the challenge of rebuilding our medical system to withstand the next crisis, medical students must critically appraise all aspects of our intellectual inheritance and let the full truth lead us where it must.
Image credit: “Doctor examines patient” (CC BY-NC-ND 2.0) by World Bank Photo Collection
Contributing Writer
University of California, San Francisco-University of California, Berkeley Joint Medical Program
Adrian Anzaldua is a fourth year medical student at the UCSF/UC-Berkeley Joint Medical Program, class of 2021. In 2009, he graduated from Stanford University with a Bachelor of Arts in philosophy. He also holds a Masters of Science from UC-Berkeley School of Public Health. After medical school, Adrian will pursue a career in Psychiatry.