By James Borders, MD
Recently, I had the honor as LMS president of addressing the freshman class of the University of Kentucky College of Medicine on their first day in the classroom. I reflected upon my own recollection of that day for me, and I mentioned the experience of Dr. Jabez Galt, the senior partner of the private internal medicine practice I Joined in Dallas, Texas in 1982. He had served as a military physician during WWII- surviving the siege in Anzio, Italy. He recalled that during his medical school training, it was an accepted reality that about two classmates each year would succumb to some form of infectious disease contracted during training.
I mentioned to the class about General Robert E. Lee’s reported interaction with a young mother who had lost her husband and oldest son in the Civil War. She had the occasion to meet General Lee as she held her infant son. General Lee took the baby in his arms and gave his mother this singular advice, “Teach him to deny himself”.
The concept of the practice of medicine as a ministry or sacrificial work has faded. Interns and residents are now protected by caps on work hours in training and now emerge into practice having experienced less time with hands-on patient care than earlier generations of physicians leaving training. Proceduralists perform fewer procedures in training nowadays than before. Many new physicians are conditioned to believe that work in medical fields can be controlled to assure a balanced lifestyle. This is one of many factors leading to a proliferation of practice models restricting one’s practice to either the outpatient or inpatient arena or to work in defined segments or “shifts”.
Most areas of medical practice have become so highly specialized that the required skill sets are increasingly confined to either inpatient or outpatient practice. Several physicians must combine skills to be an effective healthcare team for complex care delivery, but this model of care lessens each team member’s ownership of an individual patient’s well-being. Indeed, the team approach to providing care may have the effect of conditioning some physicians to view themselves as dispensable to the welfare of the patients they see.
The emerging models of healthcare delivery acknowledge that no one physician has the skills or knowledge to assure that patients receive the best care available. To be “all things to all people” as many of our medical ancestors viewed themselves is both unrealistic and destructive to work-life balance. But, given the team approach to healthcare, the sense of investment and commitment patients want from each of their physicians can be more difficult to identify. Moreover, most patients want commitment and engagement from one physician with whom a long-term doctor-patient relationship has been established. Given the inability to confine disease behaviors and health crises into timeframes that allow for maintenance of the involved physicians’ work-life balance, it is imperative that students are exposed to training that prepares them for this reality.
In their book The Coddling of the American Mind, Lukianoff and Haida call out modern academia for advancing the premise that students are fragile. They blame three “untruths” for creating a culture of “safetyism” that results in insulating students from being exposed to the stressors necessary for young people’s social, emotional, and intellectual development. They claim those untruths to be “What doesn’t kill you makes you weaker”, “Always trust your feelings”, and “Life is a battle between good people and evil people”. Considering students fragile, safety from physical and emotional stress becomes necessary, even leading to protection from words that can be viewed as a form of violence to one not accustomed to hearing them. One must wonder whether a factor in some cases of physician burnout is a lack of training in tolerance, patience, and emotional and physical endurance resulting from a modern medical education. I noticed upon my own entry into practice in 1982 that the actual practice of medicine was more challenging and stressful than predicted in training. This perspective developed despite my medical training occurring in an era preceding the modern personal protection guardrails inserted into medical education.
As I gazed across the room of the entering medical school freshman class, I was impressed with the vitality, enthusiasm, and potential palpable in the room. I reminded them that the days of competition are over, that their educators are invested in them being successful, and that the person graduating last in the class will still be called “doctor”.
Let’s trust that all involved in their medical education will have faith in what these students can become and endure and will give them the challenges necessary to prepare them for the unknowns and extremes that all physicians face.
James Borders, M.D.