Distinguishing Necessary from Unnecessary Think Pieces

I was recently treated to an article in the New England Journal of Medicine by Dr. Lisa Rosenbaum titled, Being Well while Doing Well — Distinguishing Necessary from Unnecessary Discomfort in Training. This article has apparently been making the rounds amongst hospital administration, program directors, chairs and policy makers in the medical education field. Here is the overall thesis:

“Mitchell writes that “Discomfort is part of the human condition and a prerequisite for learning. Violence and oppression are to be avoided but not discomfort. The ability to discern the difference is a form of emotional maturity we should encourage.” 

Because the ability to make such distinctions is also critical for trainees, medicine faces a bind. Our educational systems have clear shortcomings. But maintaining our commitment to excellence while remedying our failures requires distinguishing unnecessary harms from necessary discomforts. So why has it become so hard to make these distinctions?

Rosenbaum then goes on to hand-wave any and all frustrations with the current culture of medical training and drop pearls of wisdom such as: 

But when every ill feeling is labeled “trauma,” distinguishing among harms of varying magnitudes becomes difficult…

A truly rigorous examination of the troubles that medical students and residents deal with on a daily basis, boiled down to, every complaint = trauma. In Rosenblaum’s narrow worldview (she is Harvard faculty and could not help but mention that her mother was also a cardiologist), every trainee is shouting ‘trauma’ whenever a patient says they are too young to be a doctor.

She then spends the rest of the article sharing a number of the silliest anecdotes that have surely ever been printed by the New England Journal of Medicine in order to explain how the tides have shifted and, in her own words, “the silent majority” no longer feel safe to speak up.

First there is Dr. A who did some extra administrative work as a medical student and “sensed that some of his peers disapproved.” Dr. A was never bullied, ostracized or punished for this. In fact, none of his peers ever said a word to him about it. 

Next we have Dr. S, a chief resident who loves arriving early and staying late. Dr. S thrived in the “traditional hierarchy”, but now, “In the new order, high status was accorded to people who spoke out about the ways in which the demands of residency, such as high caps on admissions or long-call durations, were not simply exhausting, but unjust or injurious.” Her co-residents voted, as a group, to do away with a “long-call pilot program” because they found it harmful to their well-being. They didn’t stop taking call. There were no gaps in coverage. They simply changed the schedule slightly. Dr. S did not approve and felt “It becomes unconscionable not to comply,” she says. “Then you are oppressing them.”

Now we have (my favorite) Dr. W. Dr. W “who chairs a highly ranked surgical department”, held a regularly scheduled conference “focused on problems with the culture of medicine.” Despite the theme of the conference, Dr. W decided to spend his time showcasing the department’s Twitter feed which exclusively highlighted awards won, research grants received, and U.S. News and World Reports rankings of his department. In Dr. W’s retelling, the issue was that trainees felt that showing other’s success was harmful to them. He tries to explain how this wasn’t his Twitter feed, the Marketing department ran it! But he is rudely cut off by a resident who says that he is gaslighting them. 

Dr. W, who is shaken to his core (some might say traumatized), has a meeting with his executive coach. The coach asks him, “Did you feel comfortable speaking?” Dr. W. said no. The coach replied, “Then it’s not a safe space.”

Who will stand up for department chairs of highly ranked surgical departments with executive coaches? Who among us is brave enough to take up the cause of the traditional hierarchy and shut those unruly residents up?

Next we have Dr. Rosenbaum herself, recounting a story from her time as a medical student. She “received feedback from a renowned attending — or more precisely, from his fellow, to whom he’d outsourced that unfun task.” This renowned attending (or more precisely, his fellow), told the author that she “came off as too youthful, perhaps unserious, definitely naive.” She was told that she should change her hair, or better yet, her voice. The fellow assured her, “We just want what’s best for you.”

Rather than critically examining how such asinine feedback from a “renowned attending” might be harmful to a young, female medical student, Dr. Rosenbaum remarks “I also understood that the attending was genuinely trying to help me fit into a culture he didn’t know how to change.” This powerless, renowned attending was so concerned with young Lisa’s development that he sent his fellow to admonish her for being too young and demanded that she change her hair and voice. All very normal and appropriate things for older, male attendings to demand of female medical students. 

It also appears to be completely lost on Dr. Rosenbaum that not every medical student’s mother is a chair at the American College of Cardiology. Not everyone can simply brush off the impossible feedback from a renowned attending at their institution, and perhaps, removing this sort of illegitimate behavior from medical training, should be considered ‘Necessary.’ 

There are several other anecdotes and vague references to being ‘woke’ or ‘traumatized’, as well as the dangerous power of social media to silence the ‘traditional hierarchy.’ Dr. Rosenbaum calls upon the now all too familiar rhetoric of, ‘Has this gone too far? Yes, I am in support of x,y,z rights, but have we given them too much power?’ It is especially nauseating to hear the same tired argument, propped up as a legitimate think piece in a distinguished medical journal, about how all doctors will be poorly trained if we don’t keep doing things the exact same way that they have always been done. 

I would challenge Dr. Rosenbaum, and those that find her article to really resonate, to heed their own advice and consider that their discomfort with the ‘new world order’ may in fact make them a better doctor.


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