The Necessary Discomforts: Redefining Challenges in Medical Practice

I coach with Better Together, a group of physician coaches who work with medical students, trainees, and faculty.  (It’s excellent.  Check it out here: Better Together Physician Coaching.)  This month's coach meeting centered on a recent-ish piece in JAMA from Lisa Rosenbaum, M.D., “Being Well while Doing Well - Distinguishing Necessary from Unnecessary Discomfort in Training.”  I highly suggest you read it, but the TL;DR is that some people have found certain aspects of medical training arduous to the point of damaging their mental health, but perhaps some discomfort is necessary to learn how to practice medicine.  Staying late to care for a sick patient, admitting to the point of being capped, navigating often-clunky phone trees to chase down something (or someone) from an outside hospital, and getting feedback that stings and bruises the ego a bit are all things that were just “what we did” as medical students and residents.  These things are now being scrutinized as to whether they are unacceptably broken parts of our medical training system.  Well, except for me and the admitting to the point of being capped because (adjusting my reading glasses, pulling up my compression socks, and massaging my aching lower back), back in my day, we didn’t have caps ;)  While acknowledging that there are parts of our medical training system that are indeed broken, such as the history of people who are minorities not having a fair chance to become physicians, Dr. Rosenbaum wrestles with whether the inconveniences involved in learning to practice medicine require change to protect trainees’ mental health.  She quotes Jessica Bennett, a New York Times opinion writer, to ask, “If everything is ‘trauma,’ is anything?”

I used to think there were three medical generations: faculty, residents, and students.  But opinions within those “generations” are changing, so I can’t lump everybody into those three categories anymore.  One of the coaches in the meeting described discussing the JAMA piece with different team members.  The senior residents took her view of the piece, that it was right on and that a certain amount of discomfort is necessary while learning how to practice medicine.  The interns, however, the ones actually in the trenches of learning to care for the sick patients and admitting to the point of being capped (while also on hold with an outside hospital and hearing the attending ask, “Hey, got a minute for some feedback?”), listened to the attending and senior residents’ opinions and basically replied, “Okay, Boomer.”  The interns thought the senior residents had drunk the Kool-Aid of oppression in medical training.  There’s only a year or two between the groups.  Things are changing, and they’re changing fast.

I had my own experience with this last week while teaching medical students.  I didn’t recognize it then; I thought it was just a one-off experience.  We were discussing ethical dilemmas in the care of pediatric patients, and the conversation came up about whether a physician’s personal life should impact the care they provide patients.  (For context, we were discussing whether it was ethically acceptable for a physician who offers gender-affirming care for patients to “abandon” her patients in a state with laws banning such care by moving to a state where no such laws exist.  Or is she obligated to continue practicing in her current state and choose between providing sub-standard (but legal) treatment for her patients or providing complete treatment that risks her being sued or even arrested?  Y’know, light, easy topics.)  I asked the students, “Well, what about ‘Eat when you can, sleep when you can…’” and trailed off, expecting them to recite the end of the old medical training adage.  They stared at me and shifted in their seats when I didn’t continue.  “You all don’t know that?  ‘Eat when you can, sleep when you can, don’t stand when you can sit, and don’t mess with the pancreas’?  As soon as our white coat ceremony was done, that was drilled into us, teaching us that our needs came squarely after patients’.  Hungry in the OR?  Too bad because there was a retractor with my name on it that needed holding.”  They continued to stare.  A couple shrugged their shoulders.  “Huh,” I mused out loud, “Maybe that’s not how we’re teaching anymore.  Maybe we’re acknowledging that there’s a limit to how much we should prioritize our patients over ourselves.”  But I thought the experience was a fluke, like I somehow came across an admittedly large group of students who had never heard what The Lord’s Prayer was for my classmates and me.

I can discuss boundaries with the best of them (and have here, here, and here).  Given I work in a pediatric intensive care unit and am a clinical ethicist (and am apparently of the “older generation” in this debate, given my Gen Y status), it’s probably not surprising that I’m coming down on the side that some discomfort is necessary to practice medicine.  This means some discomfort is required to learn how to practice medicine.  A quote I’ve heard attributed to Mary Barra, the CEO of General Motors, is, “Comfort and learning are mutually exclusive.”  Learning requires some discomfort.  And given how complicated our patients’ pathophysiologies and socio-emotional lives have become, a fair amount of learning is needed, even for us attendings.  This means nearly constant discomfort may be required - even for us attendings.  So, there’s a practicality in learning how to be uncomfortable while in medical training: it makes sense to get the repetitions in, as it were, while there are safety nets.     

I do have a kumbayah, “we’re all this together,” moment before you stop reading with an “Okay, Boomer” and an eye roll while canceling me.  We are all trying to find our way in this brave new world practice of medicine.  All of us, medical students, trainees, and faculty, must figure out what discomforts we will tolerate to get the results we want individually.  Systemic racism in medicine?  That’s not the result I want, so I will take on the discomfort of changing it, even if that means correcting mistakes I didn’t know enough to know were mistakes.  My patient’s family feeling our institution is giving their child the best care possible?  That is a result I want, so I will take on the discomfort of navigating premier institutions' phone trees to get second opinions.

Because I’m accepting that we’re all going to have to do this work for ourselves, based on our unique values, I’m going to have to give the responsibility of people’s results back to them.  A medical trainee refuses to help with an admission because they’re over their cap?  Okay, they have decided what amount of discomfort they’re willing to feel, and the results of that decision are theirs, not mine.  And who knows?  Maybe that person is doing it right!  Just as well-being is highly personal, our practice of medicine will become highly personal.  And there’s nothing wrong with that.  We’ve all chosen medicine (nobody’s forced us into it), so there is something each of us has been called to do to care for the patients who need us.  Let’s start there.  We all choose to be here and have unique skills to improve our patients' care.  Medical practice can be better because of our differing views, not despite them.  

Except for differing views about the pancreas.  Never, ever mess with the pancreas.