Better in their words…

Continuing our commentary on Lisa Rosenbaum’s recent work, today we have the first of a two part piece by Dr. Cory Rohlfsen who has written terrific, thought provoking pieces for Sensible Medicine in the past.

Adam Cifu

The episode “Tough Love” from the NEJM “Not Otherwise Specified” podcast has struck a nerve as it approaches 1 million views on “X” (formerly Twitter). The polarizing responses of current trainees, younger faculty, and more seasoned doctors highlight a generational tension in regards to how we perceive, approach, and navigate our roles between work and home. Some work to live. Others live to work. While generational differences are not unique to medicine and far from dichotomous, “X” did what it does best and amplified the most extreme voices in the room.

Some faculty quietly celebrated the candor of a former medical school dean who compared medical students to adolescents and a few trainees responded with cries of “paternalism” or slurs of “boomer.” As more and more trainees reject medicine as a “calling,” an increasingly acceptable refrain of “it’s just a job” has emerged. The result? Gen X and Baby Boomers are questioning not only the younger generation’s commitment to medicine but also their confidence in medical training. These suspicions are not baseless as a 2023 Elsevier survey suggests a majority of trainees are struggling to imagine themselves shouldering a career in direct patient care. This begs the question, “what has changed?”

It would be lazy and irresponsible to chalk up the gamut of perspectives to generational “differences” in work ethic. A more inquisitive approach would seek to understand why the educational bargain feels more fractured now despite ACGME work hours being more “protective” than ever before. I’ve heard arguments that frame this discussion in terms of trainee wellness, physician burnout, social contract, and patient outcomes. I’d like to focus on what I consider “the heart” of the issue – our evolving identity as doctors.

Some consider identity transformation (the process of becoming a doctor) as the “highest purpose of medical education.” In this post, I’ll contextualize key tensions at play that make this process more difficult before offering solutions in Part 2 (stay tuned).

“Kids These Days”

Before we can discuss how our professional identities are evolving, we have to start with how the educational bargain has shifted. Medical school used to promise a future as an independent doctor but this is no longer the case. I don’t think students choosing to sacrifice a decade of their lives towards an uncertain future are lacking work ethic, so it’s about time we retire the tired trope of “Kids These Days.” The reality is current trainees work as hard (if not harder) than generations before them. Medical education remains incredibly competitive and we continue to select from the most motivated and talented pool(s) of learners. Moreover, the sacrifices trainees make today are just as significant (if not more impressive) than generations before when considering the increased cost of living, time delay(s) to start a family, and total debt accumulated – now on pace to be $300,000+ per medical school graduate. The cherry on top of lackluster remuneration and rising debt are the perils of matching into a specialty. Given the bottleneck and chaos of the match, there are increasingly no guarantees for otherwise qualified applicants. Especially now that USMLE Step 1 is “pass / fail,” trainees have less opportunities to differentiate themselves from others. The result? Publication proliferation, joyless learning, and pressures to perform like never before. In short, it’s a mistake to picture medical students on their wellness days off just “kicking their feet up.” They’re more likely to be found re-formatting and submitting research manuscripts in order to pad their CV.

Collective in-competence

Now that we’ve tackled what’s changed as a medical student, let’s consider how the clinical demands have changed as this is the milieu in which identity formation (or erosion) occurs. The analogy of a physical hospital expanding from its original isolated ward to become an interconnected quaternary care center may help. With rare exception, most hospitals get the job done but care gets delivered amidst a bizarre arrangement of disparate towers, phone lines, fax machines, secure messaging platforms, ever changing EMR updates, and the occasional beautiful atrium that tends to overshadow the original ward.

Additionally, the demands of today’s physician are immense. The task of achieving excellent (or even competent) care for high acuity patients with little margin for error is challenged further by expectations for high efficiency / throughput, making it impossible for an individual physician to single handedly provide comprehensive medical care. As an internist, I find this humbling. Whatever pursuit of excellence I seek as a hospitalist or primary care doc, the rate limiting step for the majority of my patients’ care is defined by the system around me.

Put simply, the days of heroic medicine are over. Collective competencematters more than individual competence in the 21^st century. The individual talent of plumbers, electricians, and contractors matters less than their ability to work together to deliver timely and coordinated care. Physicians are now primarily thought of as team leaders, patient advocates, and trusted co-pilots amidst a backdrop of increasing patient complexity, sub-specialization, and fragmented health systems. To go about patient care alone in today’s world is to never sleep, make innumerable mistakes, and fail your patient(s) time and time again. We are no longer exceptional because we work long hours, study hard, or think of a diagnosis that no one else did; we are exceptional because we operate seamlessly within a team, navigate novelty with precision, and know when and how to ask for help. The argument that we “have earned” the right to dictate the care plan by working long hours is superseded by the reality that the best plans are co-constructed and evidence-based.

Interconnectivity

The other significant generational shift in our work is the speed and accessibility of our connections with patients. Below is a screenshot of my cell phone which shows how many different ways a patient or triage nurse could contact me (I don’t text my patients or clinic nurses, but some primary care docs do). The same phone I use to video chat my kids to say good night has been bombarded by new ways to reach me. Like a disorganized hospital metropolis connected by haphazard networks of tunnels, skywalks, and parking garages, we cannot effectively navigate our day without becoming facile in each mode of connection. For clinic-based care in particular, the most significant catalyst of this interconnectivity was the COVID pandemic during which time electronic visits, e-consultations, and tele-health became the norm.

The reason this is important is because the impact of this sudden interconnectivity affects trainees disproportionately. I’ll never forget when our hospital adopted the secure messaging platform “PerfectServe” because we could not “turn off” the app to unplug without deleting it from our phones. Residents would often put themselves in “procedure mode” on their days off to avoid misdirected messages. My wife wasn’t too pleased by this and it came to a head during my first supervising month when I was interrupted on a family walk with our newborn to triage an urgent nurse message. Usually, I would wait until after a family stroll to forward a message on but this one read “BP 88/45, please come to bedside.” The only option(s) were to ignore it, forward to my team devoid of context, or call the nurse back. What made this more frustrating was it was not even a hospital medicine patient and the call back number was incorrect. As a result, what should have been a 2 second inconvenience ended up being a 10 minute triage task of sudden anxiety on my one day off that week.

As one who takes pride in patient care and family values, this was the first time I felt the gravity of such life-work tension. As all doctors learn in the throes of direct patient care, the demands of constantly patching the holes of an incompetent system eventually take a toll. And in the era of interconnectivity, that toll is not just immense, it’s pervasive.

Negotiating the physician identity

How well is our traditional, self-sacrificial identity of “patient-centered care at all costs” serving us in this new era of interconnectivity? Burnout rates have never been higher. 1 in 7 doctors struggle with a substance use disorder. And is anyone optimistic that the individual advocacy efforts of doctors is a sustainable solution when the complexity of patient care is outpacing the competency of our health systems?

Herein lies 3 paradoxes for the physician identity:

1)      Attribution of competent care to an individual doc has never been lower yet the stakes of individual advocacy and identity have never been higher.

2)      As the diffusion of accountability and responsibility has spread across “high reliability” systems, (causing role confusion like never before), the ability and agency of individual docs to model patient ownership and teach advocacy for learners has only diminished.

3)      As accessibility to clinic-based care has further eroded boundaries between work and home, we’ve never been more polarized on defining what “healthy” work / life integration looks like.

As disheartening as this post may be, I look forward to discussing innovative solutions on how clinician educators can preserve the best of this profession in the next post. It’s time we talk about our identity because that’s what hangs in the balance.

Cory J Rohlfsen is a hybrid internist, core faculty member at UNMC, and the inaugural director of Health Educators and Academic Leaders which focuses on competency-based approaches to developing future leaders, scholars, and change agents in health professions education.