The Pitt on Why Residents Can't Have Boundaries

There are no personal solutions to structural problems

The Pitt is far and away the most accurate depiction of residency I've seen on TV. But there's a moment in Season 2 where the Internet’s reaction — and what the show itself seems to say —doesn’t line up with what I’ve seen in my 6 PGYs. 

It's when Joy (who we might as well call Student Doctor Wednesday) leaves early, citing that over 60 percent of ED docs experience burnout:

"maybe all you lunatics need to learn how to set some boundaries, like me.” she says. “See you tomorrow, doc."

The attendings in the show shrugged, and the residents said, well, ok, good for her. The Internet cheered her for setting boundaries. 

I’m sorry to burst your bubble, but: that’s not how that would’ve played out in real life.I’ve been in the system long enough to learn the core truth about how it works, and it’s this: 

Residency is a zero-sum game.

Joy leaving early means one of those suffering, sweaty residents had to stay even later to tie up whatever loose ends she left and to finish dictating those infernal paper charts into the almighty EMR.

The work doesn't just disappear if you put your foot down. It gets absorbed by whoever is still there. And that person is always going to be one of the co-residents. And you KNOW that person needs a shower and a nap and a snack and a day off just as badly as you do.

Boundaries are a personal solution. But there are no personal solutions to structural problems.

(And before you say it, no I didn't forget that Joy is a med student!! That only makes it worse. On paper, she's junior to the residents. But in practice — in the hierarchy of who gets to leave, who gets to have a life, who gets to set a limit without cost, who gets listened to if they have a problem — she is above them. Just ask any attending who relies on med student evals for promotion.)

Horizontal hostility and the not-so-hidden curriculum

You figure out the zero-sum math pretty fast as a resident, because they tell you at orientation, just not in so many words:

Service. Professionalism. Collegiality. All of these words (which describe real things that are great!) are what will be repeated back to you if you try to do what Joy does. And not just from the faculty; they’re words your co-residents will use as well. Hell, I've said them myself, though I'm not proud of it.

I’ve said things like that in a state of what you might call burnout. But even burnout–that dreaded affliction we are all advised to guard against with yoga and therapy and hobbies and such–is another example of conflating the personal and the structural.

In 2019, the World Health Organization formally reclassified burnout in its International Classification of Diseases as an occupational phenomenon. (for you coding nerds, it’s ICD-11 QD85). What that means is that by definition, burnout is a property of the workplace, not of the worker. Burnout is the system's fault, and even the WHO thinks so. 

It’s sort of funny, then, when you think about it, that we ask the system to try to help fix the burnout. It’s like asking Staph aureus to stop making abscesses, or if those pesky cancer cells could please figure out how to stop themselves from metastasizing. 

There’s another term that I think is more useful for this mess we’re in, and it actually comes from the nursing literature. Nurses have been writing about it for decades as horizontal hostility (also called lateral violence) — a concept with roots in feminist and anti-colonial theory, describing what happens when a group with little structural power, unable to direct its anger upward, turns sideways on itself.

That is what the zero-sum game does to residents. It tells you that the problem with the system is you, and if it’s not you, it must be your friends.

Wouldn’t it be great if I had a nice, tidy little set of solutions to offer here at the end?

I don’t; however, here are the small things that I believe are at least a step in the right direction for residents in the pipeline now:  

• Share the suck: cover for each other, and if somebody does you a favor like covering a shift or staying late when you just couldn’t, YOU should find an opportunity to do the same for them (don’t wait for them to ask).
• Name the problem: this is so simple but I think a lot of people miss it. Just acknowledge, when you are putting your co-resident in a shitty situation, that you know that it’s shitty and that it’s not personal. I think people often try to justify themselves by saying they “deserve” to miss a shift because of a doctor’s appointment or a family event or an interview or a conference or they had a harder call night last week so it evens out or whatever, and I’m not saying your justification is wrong, you’re probably right! But as the system stands now, every time you do less, somebody else does more. Just say thank you.  
• Back each other up: if somebody in your program has the courage to try to make things better, have their back. It will require you taking a risk, but they’ve already taken a bigger one so it’s the least you can do. 

And then lastly, the next time you feel the system making you into somebody you don’t want to be–when you feel yourself morphing from episode 1 hero-Robby to whoever that man was who was berating med students for having Instagrams and making jokes about patients committing suicide–remind yourself: the personal is political. This phrase has roots in major cultural movements including feminism and civil rights, and it’s just as meaningful here. 

You’re not becoming a bad person. The system is bad and what it’s asking of you is unfair, unreasonable, and even unsafe at times. Boundaries are great, but they don’t work in a zero-sum game.