How do you sleep with the sound of bullets outside?

This post starts with a story involving Twitter. So I will start with some shameless self promotion. If you don’t follow me on Twitter and are reading this, here’s the type of content you can expect:

A few days ago on Twitter, I saw something crazy was going on in Baltimore but had no idea what it was, because the media coverage was dominated by William Barr and Trump drama. As a practical matter, I live in San Diego and have not been to Baltimore in years. My friend who had lived there until very recently wasn’t answering her texts. So I used Twitter to try to figure it out.

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I can’t say I was planning to write a blog post on this, but when you have a bad-ass investigative reporter like Justine Barron wanting to hear a story about a friend’s experiences living in Baltimore, and you’re trying to make it as a writer… well, let’s just say I’m eager to tell the world this fascinating story. My friend, who I’ll refer to as L, is fine with me sharing her story, but I’m trying to respect her privacy for professional reasons.

Previously, the team of Barron and Amelia McDonell-Parry had collaborated for a season of one of my favorite podcasts, Undisclosed. The season/story arc was titled “The Killing of Freddie Gray.” This was the deeper dive into the case after the public lost interest. If you’re not familiar with the various scandals involving the Police Department, or the name “Freddie Gray” only vaguely rings a bell amongst a string of horrific videos/stories (Sandra Bland, Philandro Castile, Eric Garner, etc.), I’d encourage you to start with my discussion of the Keith Davis, Jr. case. In that post, I mentioned how L crossed paths with Freddie Gray’s twin sister. They both worked at the same hospital while L was getting her Masters of Public Health (MPH) at Johns Hopkins University and Gray’s sister was working in housekeeping. Obviously, one of those awkward situations in which you don’t discuss the obvious.

Now, I was a bit sketchy on the details of a story told by a couple texts over a year ago. So I’ll clarify the above story a bit. Yes, there were 2 shootings that affected L in the first few months she lived in Baltimore. But they were actually unrelated. The first was a neighbor who was shot by a crazy ex-boyfriend. The second? A homicide detective named Sean Suiter in the area of Bennett Place. About a 20 minute walk, or 0.9 miles from University of Maryland Medical Center Midtown Campus (UMMC-MC), where L worked for a few months after starting her MPH program. Suiter was taken to UMMC - Shock Trauma (a separate hospital) where he died. This was also where Freddie Gray died. Per L, it apparently has 9 ORs and 4 helipads and 6 different ICUs. Or something similar.

The fact that this homicide detective was Sean Suiter was lost on me until I took a deep dive into Barron’s series after the above Twitter exchange. I sent it to L as I nailed down the details. Suiter worked for the Baltimore Police Department (BPD), and his death was ruled a homicide, or maybe a suicide. L’s take on it at the time was that it’d been 3 weeks, and nobody seemed to be able to figure out what had happened, or they were covering it up, or something else sketchy was happening with the BPD post-Freddie Gray. Meanwhile, she needed to move to a safer neighborhood. After her neighbor was murdered and after classmates were assaulted during the 5 block walk north to Johns Hopkins University, she moved as quickly as possible to a safer neighborhood. When she posted a picture from the high rise she moved to, I noted dryly that she literally had moved above the gunfire, and she sheepishly admitted that, yes, that had been part of the calculus. Simply picking up and moving is not an option for many people in Baltimore, for a variety of reasons. L was fortunate enough to be able to swing it. But if there’s a point to this story, it’s to shed a light on the fact that gun violence affects everyone in Baltimore. And basically everywhere in the United States to some degree. Even the doctors.

Indeed, both doctors and the patients they treat with poor sleep have a relatively high incidence of PTSD. It’s tough to sleep well when you hear bullets fired outside your when you, knowing one of them could come through your window and kill you. Doctors have to suppress their emotions while seeing horrific traumas. And working 80 hours per week for less than minimum wage… well, residents and their patients really aren’t as different as you might think.

Additionally, doctors are on the front lines taking care of the gunshot wounds. They literally put themselves at risk, as my friend did, traveling through neighborhoods in which a random bullet could kill them to provide the necessary medical care. We know we can’t fix poverty and so many of the socioeconomic determinants of health, but we do what we can for the patient in front of us. In an age of focus on patient satisfaction scores trumping the safety of healthcare workers, we have to be more skilled at de-escalating encounters with patients who may be on drugs or schizophrenic and have a gun. The BPD, and other police departments, could learn something about de-escalation techniques from doctors.

The housing and safety of those in medical training is not an issue unique to Baltimore or Johns Hopkins, though in my conversations, Baltimore seems to be up there among the more difficult cities to survive during medical training. It’s no secret that large academic hospitals treat residents like indentured servants, but you probably haven’t considered that unless someone you know has gone through it. You work over 80 hours per week and are paid less than minimum wage after having accrued hundreds of thousands of dollars of loans. In L’s case, she had completed residency the year after I did and moved to Baltimore to do her MPH in person rather than online, while working at hospitals and federally qualified health centers part time. So the financial situation at the time? Eh, not getting rich any time soon, to put it mildly.

In the process of writing this piece, I talked to a couple other friends regarding their experiences with housing in other cities during residency. One friend, who I’ll call G, is completing a General Surgery residency at the University of Pittsburgh Medical Center. She had to have parents cosign for her apartment at the beginning of residency; landlord wouldn’t accept a medical school graduate signing on solo. She’d go on to meet another resident friend of mine who used to attend the Tree of Life Synagogue, but luckily was not there at the time of the shooting just over 6 months ago. They both live in relatively safe neighborhoods close to the hospitals. Easier in Pittsburgh than Baltimore, I suspect. G notes that she interviewed at Johns Hopkins for residency, and in the 11 hours she was there to interview, 2 people were stabbed in close proximity to her.

However, the most egregious and well-known residency housing scandal is what happened at Mt. Sinai. As I was delving into the Sean Suiter articles, my friend M who lives in NYC and works as an Emergency Medicine physician called me to discuss her experience. I’d encourage you to take the deep plunge and read this Refinery29 article that lays out all the dirty details. In Manhattan, getting paid $60,000 as an indentured servant only gets you so far in the real estate market. M ranked the program second after Stanford, and one of the draws was the availability of subsidized housing literally across the street from the hospital. It was a small studio but had a doorman and had the community of the other residents/friends with whom she could commiserate. The article paints the skyscraper as a bit of a dilapidated dorm infested with rodents and cockroaches. But everyone WANTED to live there. It was cheaper and more convenient than any other option.

If you’re plowing through this post without clicking any of the links, you should note the title of the article: After 3 Physician Suicides, Mount Sinai Hospital Is Increasing Rent on Resident Housing By 40%. So, yeah, 3 physicians (2 residents, 1 attending) committed suicide in the 2 years prior to the subsidized housing and rent scandals by jumping off the roof of a 33-story building, 515 West 59th Street. Aka, the subsidized housing building.

Lured in by the subsidized housing, all the residents living there were informed in November 2015 that come June 2016 they would need to find new housing. The new subsidized housing was far east, about 45 minutes away by subway or taxi. So while sleep deprived on a medical intensive care unit (MICU) rotation, in April 2016 M scooped up a nearby apartment. Rent jumped from $1500 to $2200. Went from having laundry in the building to no laundry in the building. No doorman any more. 300 square foot 4th story walkup. Package stolen. Etc.

The hospital would never get built. Sinai lied to the residents, in M’s telling of the story. They just wanted to jack up their rent by displacing them to a new building. And maybe use the old dilapidated skyscraper for something else. Who knows. M finished out the program, vowed to never be associated with Sinai professionally. They disbanded her residency program, which had existed since 1989, so that they could use the spots to have more indentured servants in internal medicine and other specialties. One reason of many for the worsening physician shortage is that there has essentially been a freeze in Medicare funding for residency spots since the 1990s. So, yeah, disbanding a prestigious Emergency Medicine program in order to meet labor demands.

M is still in NYC and works about 32 hours per week. L moved to Denver. G will be relocating for a year for fellowship and recently got engaged to a guy she met in Pittsburgh. But a thread that weaves its way through the story is the title of this article: how do you sleep with the sound of bullets outside? We know about the neurocognitive effects of sleep deprivation. If you are working 80 hrs a week and have gunshots outside your window, you’re worse off cognitively than if you’re drunk, I suspect. And of course, the people living nearby are also dealing with low wages, working excessive hours, and stress. As noted on the Freakonomics podcast, sleep researcher Lauren Hale considers sleep to be a social justice issue. I agree with that assessment, and I think the real question for those in the medical profession is why the Accreditation Council for Graduate Medical Education continues to insist on sleep depriving those in medical training (check out page 17-19) given the negative health consequences and the current physician suicide/burnout epidemic.

I tried the Vizer app and so should you, San Diego

Undisclosed - State v. Keith Davis, Jr., Week 2