The author asserts that the medical student's after hours telephone management of a DVT establishes "character" and "moral"fiber. This ignores that teaching someone how to use sq lovenox is often best done in person, and in an integrated system there are pathways for acute care that may include the ER and acute care clinic. The author has an old fashioned view of the heroic individual doctor, on-call to her community 24 hours a day. That is a path to burnout, a luxurious scenario spun out by an academic physician.
As a woman in internal medicine I feel sympathy much more important than empathy. Empathy fatigue can be a source for burnout. The best nurse with whom I worked took Gallup strength finders and empathy was one of her lowest strengths while sympathy one of her highest. Great writing. Keep em coming.
Having practiced in the community for the past 30 years, I have no connection to what is going on in medical education and training. I also get the sense that Dr Rohlfsen does not really understand what medical practice in the "real world" has been like over the past 30 years and where it is currently!
What I do see is twofold - somewhere in medical education, it must be emphasized (and modeled) that the patient is the sacred center of our endeavors. Empathy in trainees should be nurtured (and, again, modeled). This means we don't view patients as "entitled" or focus on the "microagressions". We don't develop a "them vs us" sense. We need to understand and appreciate "human nature". Training programs must foster Oslerian ideals.
The other side of this (and the issue that stresses the ability to feel empathy) is the current status of medicine - and where it has been for the past 30 years. The physician is no longer "leader of the ship". Daily life in medicine is long hours, tedious decisions and tasks all day long, mainly working in isolation (not seeing or interacting with colleagues for most of your day). Being asked to do 45-60 minutes worth of mental work and clerical typing/data entry in a 15-20 minute chunk of time. Being told (by who? CMS?) what constitutes "quality" and how we must "measure" this. It seems that trainees are now taught that "routine physical exam" is no longer a necessary "thing". I have patients who tell me younger physicians don't generally make eye contact with them and stay at the computer typing furiously. Again, not being familiar with what trainees are being taught these days, it would be helpful to know.
How can physicians regain any leadership or influence if we no longer think eye contact or physical touch an important skill to pass along? I'm not worried (or hopeful?) about AI altering things significantly any time soon. Human connection is supremely important in the practice of medicine and a "chat bot" will not provide what patients want and need. Since AI is not as of yet reliably writing our office notes and placing all orders, I'm not sure why we focus on it changing our roles as physicians that dramatically (certain limited exceptions aside).
With a solid basis of basic medical training and information (that won't change by the time they graduate), medical trainees can join the long line and history of physicians who have kept learning their entire professional careers and stay up on what current guidelines are.
Unfortunately, I never had a mentor of any type in my medical training or practice. What I did have in medical training was camaraderie with intense friendships and "we're all in this together" feeling along with attendings who did model dedication to patient care. Patients were the center of our focus, and the interesting and stimulating discussion and debate over the best way to care for them and learn about the condition they were dealing with.
In daily practice, the tedious data entry and clerical duties that have been foisted on us by the EHR is one of the most frustrating and sole-sucking aspects. And almost complete loss of autonomy or any sense that practicing physicians have much input or direction in big decisions in our communities/national medical stage. These are probably things that need to be addressed from a trainee perspective.
Can you show me where I am advocating for ‘us vs them’ mentality or failing to embrace Oslerian ideals of patient centered care?
Can you point to the place I advocated for protecting or insulating trainees from ‘micro aggressions?’
This narrative you’re weaving is irresponsible. As a
busy primary care doctor, hospitalist, and medical educator, I fully appreciate the ‘we’re all in this together’ camaraderie approach. Education is nothing without this alliance.
Your assumptions risk being the very wedge of division that this article aimed to transcend.
I apologize if my post was taken as directed at you. Or at any particular training program. I actually found your piece somewhat difficult to follow and am not clear on what should or could change in training programs. The only thread I could really get from your piece was repeated mention of mentors. I think mentors would be great, but from my end, it doesn’t seem like the key to problems in training.
My mentioning patient-centered training was in response to some of the angst I hear from younger physicians in practice (ie, more recently trained and younger than I am). As someone else pointed out, just working for an employer and changing jobs every couple years does not develop the trust and long term relationship with patients. And I did not suggest that you, or any medical educator, is trying to “protect trainees” from “microaggressions” - what I see is younger physicians now going after patients for “microaggressions”! I, personally, observe a more recent trend toward labeling patients as “entitled” and in physicians deciding to confront patients on “microaggressions”, which is where I observe a loss for the view of the patient always the center with us as the professionals needing to deal with human nature - not get angry at and confront “problem patients”. Osler pointed out the “problem patient” is how we learn about human nature and it is our job to learn it. It is not appropriate for professionals (physicians) to have an interaction with another human who is sick, in a hospital gown in bed, and to confront them on what they (the doctor) has decided is a “microaggression”! The power differential there is huge.
I fully believe that any change in attitude of more recent trainees is due to the shifts in medicine that have made daily work more tedious, clerical-focused, etc and not to any moral failing of younger generations. I think that is where much of the focus should be.
Again, I did could not fully follow what all your points were and you misunderstood mine. I was most definitely not trying to attack you, any educator or recent trainee. Just my observations of what I see going on outside of the educational towers.
There are some general banalities here that are not objectionable. Yes, finding a role model is always useful. “Mentoring” is required, since medical training is one long apprenticeship. Longitudinal clinics are useful for trainees, because that’s what clinical practice looks like for many/most physicians….so what better way to learn about real life than in a supervised environment using a scaled down version.
But a trainee who has a role on a service requiring a pager accepts a call at 6pm and finds it tolerable only cuz he’s built a relationship with his mentor and it had been a good one?!? What?!? If you’re on service and you’re on a pager, then let’s go son! Get ‘er done! I don’t need to coddle you for a month and get on your good graces before I can expect some work out of you (and some clinical experience and teaching for your benefit). These things are called teaching services for a reason: to get your teaching, you’re gonna need to provide some service. It sounds like the case in question did have useful teachable moments. But even if it didn’t, the point is it is part of the job.
It’s the quid pro quo of medical training, I imagine, since time immemorial. And I don’t see it changing. But as was clear from the part 1 post, and the NEJM article that spawned such discussions….I am not hopeful of the younger generation as a whole stepping up and doing the necessary work. Too much worrying about triggers and micro aggressions. Too little self reflection of “this is what I signed up for”.
These ideals of stoicism, exceptionalism, and self sacrificial work ethic are not innately wrong. I too am tempted to take pride in the crucible of medical training but doubt the benefit of flexing adds any value to the conversation. Again, personal fortitude / resilience is a worthy ideal… it’s just insufficient and hasn’t served the profession well, particularly as competence has become increasingly distributed. You may need to re-read Part 1. Putting privilege / survivorship bias aside, this conversation is bigger than ‘are the canaries as tough as they used to be?’ I’m all for hard training. Not a fan of soft thinking though. Respectfully.
Not only are “stoicism, exceptionalism, and self sacrificial work ethic” not innately wrong; they’re aren’t wrong, period. And not only should personal fortitude and resilience be “worthy ideals”; we should strive for them to be common-place. Coddling and hand-holding is what produces a generation of people who lack all those things, as we are seeing now, in general society, but also coming up through medical training. You should read Jonathan Haidt, not only for his stuff on social media, but for his stuff on fragility…which seems to describe late millennials and Gen Z type to a T.
Being a doctor is a privilege, which comes as a culmination of many years of hard work and sacrifice. With that privilege comes a certain personal responsibility, to do your job and to do it well. And yeah, that means hard work.
There is nothing wrong with a bit of “modifying the job to suit the person”. I’m big on work life balance and do just fine with it. But you sometimes need to modify the person to suit the job. And as I said in comment to part 1, not everyone is cut out for this, and so be it. No one is owed a career in medicine. And better to find that out during medical training and weed out the chaff who can’t stand the heat of the kitchen, rather than coddling them through and foisting them on the public when they don’t have the fortitude to do the work. That’s many wasted years and dollars of training a dud.
Your entire through line to me is medical education. It seems you feel medical education needs to change. And my perspective is that the make-up of medical trainees needs to change. Now, we can’t change a coddled generation en masse. But we can certainly help them unlearn some bad and unhelpful habits they picked up from general society.
And if you want to debate whether we have a coddled generation or a generation and a half, get back to me after you read Coddling of the American Mind.
I’m a huge fan of Jonathan Haidt’s work (can’t wait to read his new book coming out). Just don’t think your sweeping generalization is an accurate characterization of what I see in current residents or fellows.
The bottleneck selection process for med school is intense. These people work just as hard and have significantly more debt, life delays, and demands on learning than even I experienced 10 years ago. Pharmacology has exploded. Sub-specialization of knowledge has reached new depths. The debate is not about ‘generational trends’ - that conflation not only misses the mark but also shifts the focus away from ‘at risk’ infrastructure which (yes) will require leadership from medical education to repair.
I’m curious - do you work with trainees? Have you seen evidence of lackluster work ethic in patient care from younger generations?
Leading edge Gen Z turn 29 this year. I predominantly work with cardiology fellows, so the next incoming class will be the first of that era. I also work with some IM residents, but usually the ones who want to be cardiology fellows one day, so work ethic has not been an issue….to date.
The perspective I describe is only what I’ve read and heard about the current era of med students, which seems congruent to what was described in the NEJM piece. Thankfully, I haven’t had to witness or experience any of that nonsense first hand. What I will say is that if students have such attitudes, I have no reason to expect that they would self -correct as medical graduates. So I guess we will see in the next few years if the quality of medical care suffers from the generational ills of newer physicians.
As you note, competition for medical school admission is intense….it’s a buyers market. If we are picking med students who expect coddling, maybe it’s our selection process, and not the education, that needs overhaul. Maybe we are rejecting the wrong people, when there are many other willing and eager people to choose from.
You also mentioned burn-out. No doubt an issue of our time. How is a variation in medical education going to mitigate that?
I agree entirely with the value of longitudinal clinical mentoring. As a past site director for a 3rd year LIC (longitudinal integrated clerkship) I saw first hand the intrinsic value and personal satisfaction that both students and preceptors got from a trusting educational relationship. Sadly the program was dropped because it didn't scale up..... coorporate medical education clearly values quantity over quality.
Sorry but that horse has left the barn and is long gone. The evolution from private practice to corporatism is fairly complete and the old days and ways are not coming back. As someone that entered practice in the 1970s, I had a ringside seat to watch the process. Some people blame the mindset of corporatism but its successful takeover was made possible by the intervention of government into the marketplace. Once those seeds were planted, the ultimate rot was ensured.
Unfortunately, the shift from mostly private practice to employee physicians and the self focus of the newest generation of docs( less working hours, more pay, time off, etc), has been leading to a medical culture that puts less focus on our relationships with our patients. Docs can switch jobs when they don’t feel “ happy” easily; they don’t need to build a practice by word of mouth , so they don’t really have to invest the same kind of emotional energy and may never develop the relationships with patients that encourage real concern . You react differently to that 3am phone call when you care. After 32 years in one practice, I know. I was a graduate of Hahnemann. Sad.
Agree that the ‘house of medicine’ (who owns it) fell long ago. Other professions wouldn’t have allowed privatized interests / influence like we did. Our altruism while helpful for patient care, hasn’t always served the profession well. Your point of having an increased personal stake being a ‘protective factor’ in preserving professional ideals is well taken. Sad that ship has sailed. I’m probably naive but am hoping there’s a re-invigorated interest in our collective influence / advocacy.
The author asserts that the medical student's after hours telephone management of a DVT establishes "character" and "moral"fiber. This ignores that teaching someone how to use sq lovenox is often best done in person, and in an integrated system there are pathways for acute care that may include the ER and acute care clinic. The author has an old fashioned view of the heroic individual doctor, on-call to her community 24 hours a day. That is a path to burnout, a luxurious scenario spun out by an academic physician.
As a woman in internal medicine I feel sympathy much more important than empathy. Empathy fatigue can be a source for burnout. The best nurse with whom I worked took Gallup strength finders and empathy was one of her lowest strengths while sympathy one of her highest. Great writing. Keep em coming.
Having practiced in the community for the past 30 years, I have no connection to what is going on in medical education and training. I also get the sense that Dr Rohlfsen does not really understand what medical practice in the "real world" has been like over the past 30 years and where it is currently!
What I do see is twofold - somewhere in medical education, it must be emphasized (and modeled) that the patient is the sacred center of our endeavors. Empathy in trainees should be nurtured (and, again, modeled). This means we don't view patients as "entitled" or focus on the "microagressions". We don't develop a "them vs us" sense. We need to understand and appreciate "human nature". Training programs must foster Oslerian ideals.
The other side of this (and the issue that stresses the ability to feel empathy) is the current status of medicine - and where it has been for the past 30 years. The physician is no longer "leader of the ship". Daily life in medicine is long hours, tedious decisions and tasks all day long, mainly working in isolation (not seeing or interacting with colleagues for most of your day). Being asked to do 45-60 minutes worth of mental work and clerical typing/data entry in a 15-20 minute chunk of time. Being told (by who? CMS?) what constitutes "quality" and how we must "measure" this. It seems that trainees are now taught that "routine physical exam" is no longer a necessary "thing". I have patients who tell me younger physicians don't generally make eye contact with them and stay at the computer typing furiously. Again, not being familiar with what trainees are being taught these days, it would be helpful to know.
How can physicians regain any leadership or influence if we no longer think eye contact or physical touch an important skill to pass along? I'm not worried (or hopeful?) about AI altering things significantly any time soon. Human connection is supremely important in the practice of medicine and a "chat bot" will not provide what patients want and need. Since AI is not as of yet reliably writing our office notes and placing all orders, I'm not sure why we focus on it changing our roles as physicians that dramatically (certain limited exceptions aside).
With a solid basis of basic medical training and information (that won't change by the time they graduate), medical trainees can join the long line and history of physicians who have kept learning their entire professional careers and stay up on what current guidelines are.
Unfortunately, I never had a mentor of any type in my medical training or practice. What I did have in medical training was camaraderie with intense friendships and "we're all in this together" feeling along with attendings who did model dedication to patient care. Patients were the center of our focus, and the interesting and stimulating discussion and debate over the best way to care for them and learn about the condition they were dealing with.
In daily practice, the tedious data entry and clerical duties that have been foisted on us by the EHR is one of the most frustrating and sole-sucking aspects. And almost complete loss of autonomy or any sense that practicing physicians have much input or direction in big decisions in our communities/national medical stage. These are probably things that need to be addressed from a trainee perspective.
Can you show me where I am advocating for ‘us vs them’ mentality or failing to embrace Oslerian ideals of patient centered care?
Can you point to the place I advocated for protecting or insulating trainees from ‘micro aggressions?’
This narrative you’re weaving is irresponsible. As a
busy primary care doctor, hospitalist, and medical educator, I fully appreciate the ‘we’re all in this together’ camaraderie approach. Education is nothing without this alliance.
Your assumptions risk being the very wedge of division that this article aimed to transcend.
I apologize if my post was taken as directed at you. Or at any particular training program. I actually found your piece somewhat difficult to follow and am not clear on what should or could change in training programs. The only thread I could really get from your piece was repeated mention of mentors. I think mentors would be great, but from my end, it doesn’t seem like the key to problems in training.
My mentioning patient-centered training was in response to some of the angst I hear from younger physicians in practice (ie, more recently trained and younger than I am). As someone else pointed out, just working for an employer and changing jobs every couple years does not develop the trust and long term relationship with patients. And I did not suggest that you, or any medical educator, is trying to “protect trainees” from “microaggressions” - what I see is younger physicians now going after patients for “microaggressions”! I, personally, observe a more recent trend toward labeling patients as “entitled” and in physicians deciding to confront patients on “microaggressions”, which is where I observe a loss for the view of the patient always the center with us as the professionals needing to deal with human nature - not get angry at and confront “problem patients”. Osler pointed out the “problem patient” is how we learn about human nature and it is our job to learn it. It is not appropriate for professionals (physicians) to have an interaction with another human who is sick, in a hospital gown in bed, and to confront them on what they (the doctor) has decided is a “microaggression”! The power differential there is huge.
I fully believe that any change in attitude of more recent trainees is due to the shifts in medicine that have made daily work more tedious, clerical-focused, etc and not to any moral failing of younger generations. I think that is where much of the focus should be.
Again, I did could not fully follow what all your points were and you misunderstood mine. I was most definitely not trying to attack you, any educator or recent trainee. Just my observations of what I see going on outside of the educational towers.
There are some general banalities here that are not objectionable. Yes, finding a role model is always useful. “Mentoring” is required, since medical training is one long apprenticeship. Longitudinal clinics are useful for trainees, because that’s what clinical practice looks like for many/most physicians….so what better way to learn about real life than in a supervised environment using a scaled down version.
But a trainee who has a role on a service requiring a pager accepts a call at 6pm and finds it tolerable only cuz he’s built a relationship with his mentor and it had been a good one?!? What?!? If you’re on service and you’re on a pager, then let’s go son! Get ‘er done! I don’t need to coddle you for a month and get on your good graces before I can expect some work out of you (and some clinical experience and teaching for your benefit). These things are called teaching services for a reason: to get your teaching, you’re gonna need to provide some service. It sounds like the case in question did have useful teachable moments. But even if it didn’t, the point is it is part of the job.
It’s the quid pro quo of medical training, I imagine, since time immemorial. And I don’t see it changing. But as was clear from the part 1 post, and the NEJM article that spawned such discussions….I am not hopeful of the younger generation as a whole stepping up and doing the necessary work. Too much worrying about triggers and micro aggressions. Too little self reflection of “this is what I signed up for”.
These ideals of stoicism, exceptionalism, and self sacrificial work ethic are not innately wrong. I too am tempted to take pride in the crucible of medical training but doubt the benefit of flexing adds any value to the conversation. Again, personal fortitude / resilience is a worthy ideal… it’s just insufficient and hasn’t served the profession well, particularly as competence has become increasingly distributed. You may need to re-read Part 1. Putting privilege / survivorship bias aside, this conversation is bigger than ‘are the canaries as tough as they used to be?’ I’m all for hard training. Not a fan of soft thinking though. Respectfully.
Not only are “stoicism, exceptionalism, and self sacrificial work ethic” not innately wrong; they’re aren’t wrong, period. And not only should personal fortitude and resilience be “worthy ideals”; we should strive for them to be common-place. Coddling and hand-holding is what produces a generation of people who lack all those things, as we are seeing now, in general society, but also coming up through medical training. You should read Jonathan Haidt, not only for his stuff on social media, but for his stuff on fragility…which seems to describe late millennials and Gen Z type to a T.
Being a doctor is a privilege, which comes as a culmination of many years of hard work and sacrifice. With that privilege comes a certain personal responsibility, to do your job and to do it well. And yeah, that means hard work.
There is nothing wrong with a bit of “modifying the job to suit the person”. I’m big on work life balance and do just fine with it. But you sometimes need to modify the person to suit the job. And as I said in comment to part 1, not everyone is cut out for this, and so be it. No one is owed a career in medicine. And better to find that out during medical training and weed out the chaff who can’t stand the heat of the kitchen, rather than coddling them through and foisting them on the public when they don’t have the fortitude to do the work. That’s many wasted years and dollars of training a dud.
Can you show me where any of this perspective endorsed coddling, hand holding, or training ‘duds’?
Your entire through line to me is medical education. It seems you feel medical education needs to change. And my perspective is that the make-up of medical trainees needs to change. Now, we can’t change a coddled generation en masse. But we can certainly help them unlearn some bad and unhelpful habits they picked up from general society.
And if you want to debate whether we have a coddled generation or a generation and a half, get back to me after you read Coddling of the American Mind.
I’m a huge fan of Jonathan Haidt’s work (can’t wait to read his new book coming out). Just don’t think your sweeping generalization is an accurate characterization of what I see in current residents or fellows.
The bottleneck selection process for med school is intense. These people work just as hard and have significantly more debt, life delays, and demands on learning than even I experienced 10 years ago. Pharmacology has exploded. Sub-specialization of knowledge has reached new depths. The debate is not about ‘generational trends’ - that conflation not only misses the mark but also shifts the focus away from ‘at risk’ infrastructure which (yes) will require leadership from medical education to repair.
I’m curious - do you work with trainees? Have you seen evidence of lackluster work ethic in patient care from younger generations?
Hey well we definitely share 1 thing in common.
Leading edge Gen Z turn 29 this year. I predominantly work with cardiology fellows, so the next incoming class will be the first of that era. I also work with some IM residents, but usually the ones who want to be cardiology fellows one day, so work ethic has not been an issue….to date.
The perspective I describe is only what I’ve read and heard about the current era of med students, which seems congruent to what was described in the NEJM piece. Thankfully, I haven’t had to witness or experience any of that nonsense first hand. What I will say is that if students have such attitudes, I have no reason to expect that they would self -correct as medical graduates. So I guess we will see in the next few years if the quality of medical care suffers from the generational ills of newer physicians.
As you note, competition for medical school admission is intense….it’s a buyers market. If we are picking med students who expect coddling, maybe it’s our selection process, and not the education, that needs overhaul. Maybe we are rejecting the wrong people, when there are many other willing and eager people to choose from.
You also mentioned burn-out. No doubt an issue of our time. How is a variation in medical education going to mitigate that?
I agree entirely with the value of longitudinal clinical mentoring. As a past site director for a 3rd year LIC (longitudinal integrated clerkship) I saw first hand the intrinsic value and personal satisfaction that both students and preceptors got from a trusting educational relationship. Sadly the program was dropped because it didn't scale up..... coorporate medical education clearly values quantity over quality.
Sorry but that horse has left the barn and is long gone. The evolution from private practice to corporatism is fairly complete and the old days and ways are not coming back. As someone that entered practice in the 1970s, I had a ringside seat to watch the process. Some people blame the mindset of corporatism but its successful takeover was made possible by the intervention of government into the marketplace. Once those seeds were planted, the ultimate rot was ensured.
Unfortunately, the shift from mostly private practice to employee physicians and the self focus of the newest generation of docs( less working hours, more pay, time off, etc), has been leading to a medical culture that puts less focus on our relationships with our patients. Docs can switch jobs when they don’t feel “ happy” easily; they don’t need to build a practice by word of mouth , so they don’t really have to invest the same kind of emotional energy and may never develop the relationships with patients that encourage real concern . You react differently to that 3am phone call when you care. After 32 years in one practice, I know. I was a graduate of Hahnemann. Sad.
Agree that the ‘house of medicine’ (who owns it) fell long ago. Other professions wouldn’t have allowed privatized interests / influence like we did. Our altruism while helpful for patient care, hasn’t always served the profession well. Your point of having an increased personal stake being a ‘protective factor’ in preserving professional ideals is well taken. Sad that ship has sailed. I’m probably naive but am hoping there’s a re-invigorated interest in our collective influence / advocacy.