I’ve been thinking a lot lately about what makes a Physician a Physician. Of course, this is different for everyone: Primary Care Physicians love finding the needle in the haystack diagnosis – sifting through routine exam after routine exam and never losing complacency in order to catch the 1:10,000 diagnosis. They love longitudinal goals and longstanding relationships that help people live better – healthier, with improved mental health and care, and the like. Critical Care Physicians are a unique bunch – we of course care about catching 1:10,000 diagnoses, and we love the idea that we can run into any situation and handle it. But this isn’t what I have been thinking about.
I have been thinking about the differences between Physicians and anyone else. And as I often do, I have come to an answer with a little help from the military – of course my favorite group, the Navy SEALs. The Navy SEALs are renowned for being some of the best operators in the world, and what they are most famous for is Never Quitting. Their training trains them to be effective operators, of course, but if you’ve followed their training regimens and history, there’s a lot more to it.
In order to become a Navy SEAL, you have to do a whole lot of things that “don’t matter” towards your specific on-the-job duty. One example is running while wet and sandy. Does chafed running somehow translate to operational readiness? What about Hell Week, the famous event of no-sleep and tireless efforts and physical strain – does Hell Week teach you something valuable that you can apply in combat? Of course there are overlaps, but they aren’t exactly clear. Chafed running teaches you to ignore pain to accomplish your tasks. Hell Week weeds out anyone who will quit when the going is beyond tough. And all of it teaches you that your team – that your brotherhood – can stand together, can never quit together and will always get it done.
In many ways, Medical Training has an aspect of Painful Learning to it. And I’m going to say two things that may be unpopular:
First, medical training should be hard. It differentiates us. Do you need to be awake for 30-hours doing work in order to take care of people effectively? No. But I learned how to safely be fatigued, how to put safeguards in place so I could accomplish tasks, and I learned how to never quit. To this day, if I’m responsible for you or your parent and it’s 3 AM, and they get sick with a diagnosis I haven’t managed before — you can bet anything that I will wake up, read book chapters, review articles and be by their side until I make sure they are safe. Why? Because that was pounded into me at 3 AM during my training. I am the patient’s safety net. I am responsible. I will never quit. And of course – I’ll do that with a team of people around me, helping me and supporting me. Making training easier may improve the lives of our residents (of course it would! So would making everyone in the US work 20-hour weeks!), but it makes Medicine just like any other job. Medicine is unique because it is hard. I wear my title as a Physician as a badge of honor. I wasn’t scared to go through the extra time and pain of training in medical school, or residency, or my second residency, or my fellowship, in order to save someone’s life at 3 AM. There are many, many smarter people than me – but I will never quit.
Second, medical training should maintain incredibly high standards. And yes…this means standardized testing. Now, I hated standardized tests. They made me competitive. They made me stressed to such a degree that myself – and many of my colleagues – routinely vented to each other and to professionals (shout out to counselors!) in order to survive. The constant performance pressure and need to score was … horrible. But was everything I learned necessary? No. But it taught me how to learn. And I learned far, far more because I was scared of the test. I had no intention of practicing psychiatry, but you can bet that I still remember a host of drug interactions and approach to care for mental health and psychiatric diagnoses because I had to score highly in order to succeed at a high level!
It isn’t only the things that apply to the job that matter. Sometimes it’s learning how to learn. Sometimes it is learning how to maintain a strong, organized “peripheral brain” of material so that when someone comes to the ICU with serotonin syndrome, I can recall how I differentiate that condition from neuroleptic malignant syndrome — because I studied heavily in psychiatry. Sometimes, it is simply to prove that to be the best — to earn the badge and title of Physician, or to even be the “Physician’s Physician” — you have to work hard, study hard and maintain an Inquisitive Mind – even for things that “don’t apply.” And yes, you have to be smart. While many can work hard enough to make it into medical school, you want a Physician that can look at a 25+ patient list, get 3 urgent pages at 4 AM, and still make the right decision, the right diagnosis and the right medication selection, even when they don’t have time to look things up. That doesn’t just take work ethic – it takes study and smarts.
My final opinion isn’t as controversial in theory, but in practice it is very challenging. If Physician’s don’t want to honor the title they chose and the path they’re on, then they should get out, or be taken out of medicine. You don’t see a hard working Navy SEAL who can’t shoot, because they get kicked out. You don’t see a superstar SEAL who can shoot and run, but can’t stay up through hell week and run chafed and sore, because they are weeded out.
Something to think about. For more, take a glance at “Kicking the Can Down the Road, when Medical Schools Fail to Self Regulate” in the New England Journal of Medicine (Dr. Santen et al, 2019)- you can find it here: https://www.nejm.org/doi/full/10.1056/NEJMp1908940.
What do you think? Am I way off?