Medical education's dirtiest secret.

Nearly one hundred thousand patient deaths per year are attributed to provider error, according to a November 1999 report by the Institute of Medicine of the National Academies. Overwork and exhaustion are sources of such errors. And among all doctors, the most overworked are medical residents--medical school graduates employed by teaching hospitals ostensibly to receive training in a medical specialty but, practically speaking, to be utilized as cheap labor.

According to Jung v. Association of American Medical Colleges, a May 2002 lawsuit filed in a Washington, D.C., federal district court that challenges the residency employment system, typical medical resident work hours range from 60 to 136 per week. The starting hourly compensation rate calculates out at about $10 per hour on average. And the vast majority of U.S. medical residents aren't represented by labor unions.

Currently the New Jersey state legislature is considering limiting resident working hours. The only state which has already enacted such legislation is New York, in response to the 1984 death in New York Hospital of teenager Libby Zion, which occurred when an overworked resident declined to come to her bedside.

Since the fall of 2001, two members of Congress, Representative John Conyers (Democrat, Michigan) and Senator Jon Corzine (Democrat, New Jersey)--concerned about the threat to patient safety posed by overworked, overwhelmed, and exploited doctors' delivery of inpatient care at the nation's four hundred teaching hospitals--have introduced bills to impose a limit of eighty work hours per week for the approximately ten thousand residents. Though both initiatives are currently before committees, it could be years before the proposed legislation is adopted, if ever.

Furthermore, these efforts, laudable as far as they go, don't address many ugly abuses In medical education. Aside from exploitation of residents through failure to enforce reasonable working hours, the ugliest feature of medical education is the draconian methods that medical educators use in disciplining residents. Medical school administrators have been functionally free to resort to actionable or illegal acts such as defamation or physical mistreatment. The latter can include increasing the trainee's workload, denying leave for illness and even corporal punishment.

In my experience as a medical resident, I have observed these abuses in action. Denial of sick leave (especially extended sick leave), for example, is common. The standard rationale is that if leave were given the duties of the absent resident would become the burden of his or her peers. Indeed, I was denied sick leave more than once; on one occasion I was ordered to continue serving at the local children's hospital even after my personal physician had informed the residency program secretary that I was suffering from both strep pharyngitis and infectious mononucleosis.

Hospital administrators engage in abusive discipline because they can. The perpetrators must account to no one and nothing in the typical contract signed by a doctor joining a medical residency places limits on her or his superiors' disciplinary prerogatives. Yet such practices take place under a veil of secrecy. Those who perpetrate them depend on the intimidated silence of the victims who, after years of expensive medical school training, are afraid to risk reprisal by complaining. Abusive discipline thus thrives not only on the arrogance of the powerful but on the shame and fear of the powerless.

In the shadowy disciplinary armamentarium of medical education, the dirtiest secret is disciplinary psychiatry. It exemplifies the medical community turning on its own. Disciplinary psychiatry can be defined as coerced subjection to psychiatric intervention as a condition of remaining in training. Medical educators use it not only against doctors in residency but also against medical students in the process of earning a medical degree.

The term disciplinary psychiatry refers not to a situation in which a person with an established diagnosis of mental illness is enrolled for medical training but to one in which the medical education administrators seek to establish a diagnosis of mental illness in a trainee by forcing him or her to see a mental therapist of the institution's own choosing.

Disciplinary psychiatry likewise doesn't apply in the event that, after embarking on a course of medical training, an individual voluntarily chooses to undergo therapy with a psychiatrist or psychologist--which the supervisors happen to learn of. Disciplinary psychiatry applies, rather, to a case in which, under threat of removal from the program, an unwilling trainee is forced into treatment by a therapist chosen by her or his supervisors, with the added requirement that the supervisors can learn of the diagnosis and monitor the trainee's progress in therapy through reports provided by that therapist. In other words, it is disciplinary psychiatry when the trainee must forgo confidentiality, both as regards to the choice of therapist and the content of therapy.

Disciplinary psychiatry also doesn't apply to a situation in which a trainee has been suspended for being unable to carry out his or her duties safely (such as in a case of substance impairment) and supervisors offer a chance to undergo rehabilitative therapy in order to be reinstated. Obviously, if a trainee is a menace to patients or to the safety of coworkers, the only logical choice at the outset is to get him or her off the wards and consider rehabilitation afterward. Disciplinary psychiatry isn't the term for such a case. Disciplinary psychiatry, instead, requires a resident to undergo mental evaluation or therapy--while the resident is nevertheless allowed to remain actively engaged in patient care duties. This is what makes the practice disciplinary rather than, say, precautionary, because in such an instance there can be no pretense that the institution is intervening as a precaution on behalf of anyone's well-being. Indeed, it's possible to maintain that, in the past, the practice has been used because the trainee is of the "wrong" race, gender, or political philosophy.

The tactic of disciplinary psychiatry confronts the trainee with a catch-22. The medical education administrators don't summarily terminate the resident but they stipulate that renewal of her or his contract for the next year's training is subject to a special condition. In sum, they offer the trainee a choice of either being fired when the contract expires or submitting to evaluation or treatment by a mental health professional administrators have chosen. If the trainee accedes to this, the trainee is eventually removed from the training program anyway on the grounds that seeing a psychiatrist comprises facial evidence of his or her unfitness to ever practice medicine. But if the student refuses therapy, she or he is removed from the training program on the ground of disobedience.

Either way, a resident so removed from a training program has very little chance of ever working again as a physician. Any future residency or licensing body to which this person might apply will inquire as to the circumstances for having left a prior training program without finishing. Upon inquiry from such parties, the medical administrators will respond saying that the director of the program had instructed the trainee to undergo psychiatric intervention. The inference will be made that, if such an authoritative figure saw fit to so direct the trainee, then the trainee must, by logical inference, be mentally ill. This is the defamatory aspect of disciplinary psychiatry.

I first observed an instance of disciplinary psychiatry as a first-year medical student. In my small cohort of fourteen students only one (who I will call S) belonged to a racial minority. Like all the others in the group, S came from an affluent background. But in some ways he was less socially advanced than his colleagues, having reached the age of twenty-five without ever previously living away from home. He seemed to have difficulty being accepted by others in the cohort and formed no friendships.

Classes started in July, the traditional beginning of the academic year for medical education programs. The intensive study necessary to keep up with course requirements caused all of the students stress. But S appeared to have fewer reserves to deal with it. He got into arguments with one or two other students; he performed perfunctorily in his dissection team or failed to show up for gross anatomy altogether. He was passing his courses, but only barely. One classmate claimed to feel "threatened" by him because he invited her for a dinner date and, upon her refusal, persisted by sending her gifts of flowers and candy.

Finally, around the end of October, a student who had been designated by the administration as class representative reported that S had become emotionally distraught in her presence and had tried to lump out of a lecture hall window. There were no other witnesses. I was unable to credit this story since we had only one lecture hall and all of its windows were enclosed in metal grillwork; not even an infant could have exited from any of its windows. The administrators of the program, however, decided that his unpopularity among classmates was sufficient evidence that S was unfit to continue study. They gave him a choice of either being arrested (on what charge I cannot say) or immediately going to the psychiatric outpatient clinic of the neighboring hospital. As soon as S acceded to the latter, he was removed from the class on grounds of mental instability.

Several months later, when S applied for reinstatement he was refused. Although he had never physically threatened anyone, the administration threatened to call the police if he were seen near the medical center grounds. And they asked the remaining members of the class to report any sighting of him.

This took place in a medical school setting but the practice described is at least equally common in residency. From 2000 to 2001 I embarked on specialty training and was a resident in a neurology program at a midwestern state university hospital. During that period the program hosted ten residents. Of the ten, three were subjected to disciplinary psychiatry. Two acceded and one didn't; all three were removed from the program. Three out of ten, or about 30 percent, is a much higher prevalence of mental illness than is found in the general population--let alone among those who have the organization, drive, and faculties to matriculate in a medical school

Thirty percent is also probably higher than the usual prevalence of disciplinary psychiatry in residency programs, although this is hard to ascertain because of the secrecy surrounding the issue. Historically, both educators and trainees involved in disciplinary psychiatry have been reticent about the topic. This is understandable: the practice cannot be openly discussed when, on the one hand, the perpetrators need not justify their actions to higher authority and thus aren't required to justify their motives. And on the other hand, the trainees subjected to such therapy are reluctant to discuss it because of the shame associated with it. Accordingly, no authoritative statistics have been published as to the prevalence of disciplinary psychiatry, whether in medical school or in residency.

One thing that is known, however, is that the practice is of long standing in medical education. The American Medical Student Association, a body of thirty thousand members, has been an outspoken critic of disciplinary psychiatry. The AMSA has published warnings to trainees about the practice and has gone so far as to advise trainees (both medical students and residents) not to accede to a demand by medical educators to submit on record to psychiatric intervention. It suggests, if necessary, to seek legal counsel--pointing out that it is illegal under U.S. Code Title XX.

In my experience, when medical educators are asked in a legal context to report the prevalence of disciplinary psychiatry in their residency programs, they usually refuse to provide information on the grounds that medical residents have "student" status. Indeed, legal cases have provided authority for classifying residents as students. According to the decision in Boston Med. Ctr. Corp. v. House Officers' Assn./Comm. of Interns & Residents, medical residents have a dual legal status: they are employees of the hospitals which train them and they are also students.

But if it is true that residents have rights as students under Title XX, then the practice of medical educators' picking out a psychiatrist or other mental health professionals to evaluate and send back to the program reports on a resident's mental status is patently illegal. Another provision of Title XX designates as documents not to be included in a student's educational record without consent those "which are made or maintained by a physician, psychiatrist, psychologist, or other recognized professional.., and which are made, maintained, or used only in connection with the provision of treatment to the student."

Although disciplinary psychiatry is a notorious, if little-discussed, abuse within the medical community, it has almost never been challenged in court. But I have taken such an initiative.

While in my first year of training in a specialty I complained about a series of obscene illustrations and e-mail messages that a male colleague had sent over the medical center's Internet system. Almost immediately I was added to a preexisting small group of fellow residents upon whom the program imposed a demand to see a psychiatrist. I refused and, on grounds of disobedience, my contract wasn't renewed--although I was allowed to continue duties as usual for the remaining period of my contract.

The nonrenewal made it impossible for me to complete the residency. Nor was I successful in transferring to another one. If a resident is dismissed for either agreeing or refusing to comply with disciplinary psychiatry, the dismissing program can block her or his joining another residency by noting, when it communicates with another residency about the applicant, that the resident in question was told to see a mental therapist. Generally, one residency won't hire a resident who has left a prior residency unfinished until and unless a release letter is secured from the prior program. This fact pattern has become the basis of my federal case: Klaiman v. Ohio State University Medical Center. Because of the unusual issue involved, persuading a court of the wrongness of disciplinary psychiatry is a hard sell. The case underwent summary dismissal in a Columbus, Ohio, federal district court on January 28, 2003. Since then, it has been pending in the Sixth U.S. Circuit Court of Appeals.

However, because the case involves a state agency as defendant, a separate complaint on the matter was filed before the State Personnel Board of Review, a tribunal that regulates civil service in Ohio. Although the board initially declined to hear complete testimony in the case on the ground that medical residents purportedly couldn't be considered classified civil servants, the Franklin County Court of Common Pleas heard an appeal and, in June 2003, reversed the board decision. The state has appealed the reversal and the case is currently before the County Court of Appeals. If the state's appeal is unsuccessful, the case will eventually return before the board to be heard to completion.

Few accounts have been written by medical practitioners subjected to disciplinary psychiatry and willing to break silence afterward. But there are two of note.

In her book The Making of a Woman Surgeon, Elizabeth Morgan, M.D., recounts being subjected to a psychiatric interview as a condition of applying to Harvard Medical School in the 1960s. The requirement wasn't imposed due to any irregularity in Morgan's background or qualifications but was a standard requirement of all female applicants at the time, evidently arising out of an institutional bias that women who wanted to become doctors suffered from sexual identify confusion or worse. Morgan writes that after the interview she decided to withdraw her Harvard application and applied successfully to another medical school that didn't have a requirement for psychiatric evaluation of applicants.

John Friedberg, M.D., writes of his experience as a neurology resident in the 1970s at a West Coast residency in his book Shock Treatment Is Not Good for Your Brain. In his first year Friedberg was presented with an ultimatum to become a patient of his institution's psychiatry department or, failing that, to be fired from the residency. The cause of this ultimatum was his training program's objection to his conducting research antagonistic to electroconvulsive therapy. Friedberg comments. "It was no choice at all. I was fired." Though he brought a complaint through the federal court system, Friedberg didn't succeed in being reinstated by his program. He was eventually hired, however, by another neurology residency, the chair of which concurred with his views on shock therapy.

The accrediting body for U.S. residencies is called the American Council on Graduate Medical Education. The ACGME has the power to withhold accreditation from programs that fall to meet its guidelines.

Historically, the ACGME has shown little interest in protecting the interests of residents. It had no guideline restricting resident working hours until June 2002, when it became a defendant in the Jung case. The council reacted by establishing standards on resident work similar to the restrictions proposed in the pending federal legislation, which took effect July 2003. But residency programs can apply to the ACGME to request an exemption from the standards. And as the ACGME isn't a legislative body, its guidelines have no legal force.

The ACGME should now also impose on all US. residency programs a requirement to both explicitly agree to refrain from subjecting residents to illegal training conditions in resident contract documents and to foreswear disciplinary psychiatry explicitly in contractual agreements with residents.

Those who don't have a voice in what the ACGME does can nevertheless get involved. Indeed, it is time that all Americans stop becoming victims of abused and exhausted residents in teaching hospitals. And it is time that the government better regulate residency programs.

Mimi Klaiman, a Ph.D. and former college professor, carried an M.D. at a midwestern state medical college in 1997. She is currently a second-year law student at the University of Arizona College of Law. Readers interested in the progress of the Jung v. AAMC class-action lawsuit against the residency matching system can consult residentcase.com