Opinion
A PIECE OF MY MIND Shlok Gupta, MD Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada. Susanna Mak, MD, PhD Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada. Allan S. Detsky, MD, PhD Institute of Health Care Policy, Management and Evaluation, and Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada.
The Other Generation What are we going to do about the other generation? How will we ever communicate without communication?
those situations. So let us make difficult decisions on our own first, then teach us if you think we are wrong.
“The Other Generation” from Flower Drum Song (music by Richard Rodgers; lyrics by Oscar Hammerstein II)
Improvements in human living conditions occur inevitably over time. The unprecedented rate of change that has occurred in the last 150 years resulted from accelerated technological progress and social changes that allow us to live with more freedoms and at a higher standard than ever before. Simultaneously, the passing of time evokes tension between older and younger generations, each bemoaning their problems with the other. As life gets technologically easier, common generational caricatures emerge: older people feel that next generation lacks work ethic, discipline, and courtesy; young people think the world began the day they were born. In medicine, generational conflict occurs in a much shorter cycle of time. Senior residents look at the work habits of first-year trainees, who are only 3 or 4 years behind them, with disdain. And this phenomenon predates the recent decade of changes in work hours. The words “lazy,” “entitled,” and “uncommitted” have been used to describe those who followed in the training pathway for as long as any of us can remember. In an “Open Letter to My Elders,”1 Eric Biondi, an academic pediatrician in his first year as a faculty member at the University of Rochester, wrote: “We have so much to learn from you, the generations of physicians who came before us. … You are the keepers of the ideals of our medical forefathers, so pass those ideals on to us.” We take up Biondi’s challenge and expand it by creating an intergenerational dialogue. Each of us—a second-year internal medicine resident, a midcareer academic cardiologist, and a senior general internist—will offer 5 key messages we would like each other to hear.
Teach Me How to Manage Uncertainty and Failure
Residents are not accustomed to uncertainty or failure; in fact, many got to medical school by “being perfect.” However, in our training and careers, we will make mistakes, some of which will harm our patients. These experiences have the potential to erode our confidence. We need reminders that even our attending physicians don’t always know the answer and that sometimes even when we do our best we won’t succeed. Help Me Identify What Is, and Is Not, Important as I Make Choices That Shape My Future Career
Income, duration of training, competitiveness of fellowships, lifestyle, location, and availability of jobs are some of the factors that influence residents’ decisions about career choices. We need our mentors to help us identify which factors are short-sighted and which will be important in the future. Tell us how you made those choices: when you were right and when you were wrong. I Look to You for Inspiration
Medicine is a long road. But when attending physicians with whom we connect love their work, we know it is possible for us to be “like them” one day. So show us your passion; tell us what gets you out of bed in the morning.
Messages From a Midcareer Cardiologist Always See the Patient
With the advent of the electronic patient record, I have witnessed the comprehensive compilation of histories, physical examinations, and investigations as a trainee sits at a remote workstation far away from the patient bedside. One has to stand at the foot of many beds to develop “physician’s intuition,” which remains essential to the art of diagnosis.
Messages From a Resident I Want Medicine to Be Fun
Enthusiasm from teachers is infectious. Even rotations that require a heavy workload can be enjoyable if there is a positive team environment, teaching around cases, a sense of meaning in patient care, and acknowledgment of our hard work. When these conditions prevail, every member of the team wants to be present for patient care and learning; there is no place else we would rather be. Corresponding Author: Allan S. Detsky, MD, PhD (adetsky@mtsinai .on.ca). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
I Need to Be Given Responsibility to Grow
Themostenjoyablerotationsinresidencyarethosewhere we are challenged to the limits of our capabilities to solve meaningful problems. Difficult situations can be stressful in the moment, but nothing compares to the satisfaction and personal growth we experience from handling
Spend Time With Your Patients, Even If There Isn’t Anything You Can Do
I learned the value of accompaniment from a young man I cared for in the worst days of the HIV-AIDS epidemic, who suffered torturous discomfort from Kaposi sarcoma despite palliation. I rounded on him every day, even if only for a few minutes, until he died. Moments later, his devoted sister thanked me for not abandoning her brother in his darkest days. Now seeing patients treated with highly active antiretroviral therapy, relatively unaffected by their HIV infection, I am a frontline witness to the revolutionary gains of medical science. Learn How to Accept Criticism
We care about your success. The most valuable clinical lessons for me occurred when I was told I had made, or (Reprinted) JAMA April 7, 2015 Volume 313, Number 13
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/11/2015
1319
Opinion A Piece of My Mind
was about to make, a poor decision. If you want to learn from me, then let me criticize you. You should be made aware when you are not meeting the high expectations we have as a profession. Great emphasis is now placed on teacher evaluations that empower students to anonymously and negatively label these behaviors as intimidating rather than authoritative. If you want to keep learning, then recognize the difference between feeling appropriately chastened and being inappropriately humiliated. Remember, excellent patient care is not always about you.
uncertainty. An important skill is the knowledge of when uncertainty is acceptable, and when it is not, requiring further immediate investigation. Another skill is getting patients to understand when it is in their best interests to stop looking for the cause of their symptoms and let time determine the outcome. I use this sentence frequently: “We have done many tests to figure out what is wrong and so far none of them have given us the answer. That is a good thing because some of those answers would not be the ones you would want to hear. So now, we are just going to pause and see how things develop over time. This is good news.”
How to Handle Work-Life Balance
It is easy to feel overwhelmed by our perceptions that we are not meeting the expectations of patients or our own families. I have found that the effort to maintain control is more exhausting than simply embracing the busyness of professional and family life. There is no perfect solution. However, in my opinion, compared with physicians of an earlier era, we have more control over how we spend our time than the vast majority of people. Don’t Take It Personally
As said by American author Ann Leckie, “Surely it isn’t illegal here to complain about young people these days? I had thought it a basic part of human nature, one of the few universally practiced human customs.”2 Indeed, the old will always criticize the young. I have no idea when I became “mid-career.” For years after I completed my residency, I perceived myself as youthful and close to the trainees. But I was wrong. One of life’s cruel truths is that everyone will be “older” one day, and you too will be cranky.
Messages From a Senior Internist The Importance of Continuity
Physicians who care for patients over long periods have the advantage of intimate knowledge of the reasons for and responses to the clinical decisions made in the course of their illnesses. In addition, long-term relationships allow for the building of trust and a sense of responsibility. Patients generally prefer to see the same physician instead of starting over with a new one. Try as much as you can to emulate the spirit of “one doctor, one patient” in the care you deliver by looking for opportunities to maintain continuity. Know When to Review Images and Pathology Yourself
When key clinical decisions depend on the nuanced interpretation of imaging and pathology findings, review those yourself with a radiologist or pathologist. Face-to-face communication between the clinician and radiologist or pathologist will more often than not yield insights for both parties that will improve the decisions you will make. Learn How to Deal With Uncertainty
There will be many times when you cannot make a diagnosis and the prognosis is not clear. A good clinician learns how to manage that Additional Contributions: We thank Victor Fuchs, PhD (Stanford University), and Stephen Gauthier, MD (University of Toronto), for commenting on an earlier draft. Neither was compensated for doing so.
1320
Patients Want Hope, and Sometimes Can’t Hear Bad News
Several years ago I made a diagnosis in a man that I knew meant he was going to suffer a long and painful death. I delivered the news to him and his wife. After he died in the manner I had predicted, his wife told someone I knew that I was the only doctor who was honest with them from the start. I asked him whether she appreciated my honesty and he answered, “No, she did not.” Patients and their families are always looking for hope. There is a time when honest appraisal is warranted, but recognize that, in addition to denial as a defense mechanism that prevents accepting bad news, you may well be resented for delivering it and may want to find a way to offer some hope, even if it is only temporary. Have a Family
During your entire career, there will be a lot of people who may remember you fondly, but at the end of the day, the people you are most likely to be able to count on are the members of your immediate family, so make sure you have one (no matter how you create it). For me, the most important and satisfying thing I did was to have and raise children, although I can’t promise that they will never be a source of angst. And remember, if you choose to do likewise, there is never a good time to start, so don’t put it off too long.
This exercise has been useful because it induced each of us— separated in age by almost 20-year intervals—to reflect on the important issues we feel should be communicated to other generations without presuming whose messages were most valid or important. We each wrote our sections without the knowledge of what the others would say; so it is not surprising that some of the messages have common themes (uncertainty, mistakes, personal life), while others are completely different. We can only wonder about the messages we might have received from the generations that preceded us, or ones we might receive from those that will follow us. But for now, we believe this intergenerational dialogue, which each of you can replicate in your own settings, forms the basis of an educational curriculum to help both young and old accept the inevitability of change, while simultaneously meeting Biondi’s plea to pass the ideals of medicine’s forefathers into the future.
1. Biondi E. In defense of my lazy and entitled generation: an open letter to my elders. Hosp Pediatr. 2013;3(1):76-78.
2. Leckie A. Ancillary Justice. New York, NY: Orbit US; 2013.
JAMA April 7, 2015 Volume 313, Number 13 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/11/2015
jama.com
A PIECE OF MY MIND Shlok Gupta, MD Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada. Susanna Mak, MD, PhD Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada. Allan S. Detsky, MD, PhD Institute of Health Care Policy, Management and Evaluation, and Department of Medicine, University of Toronto; and Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada.
The Other Generation What are we going to do about the other generation? How will we ever communicate without communication?
those situations. So let us make difficult decisions on our own first, then teach us if you think we are wrong.
“The Other Generation” from Flower Drum Song (music by Richard Rodgers; lyrics by Oscar Hammerstein II)
Improvements in human living conditions occur inevitably over time. The unprecedented rate of change that has occurred in the last 150 years resulted from accelerated technological progress and social changes that allow us to live with more freedoms and at a higher standard than ever before. Simultaneously, the passing of time evokes tension between older and younger generations, each bemoaning their problems with the other. As life gets technologically easier, common generational caricatures emerge: older people feel that next generation lacks work ethic, discipline, and courtesy; young people think the world began the day they were born. In medicine, generational conflict occurs in a much shorter cycle of time. Senior residents look at the work habits of first-year trainees, who are only 3 or 4 years behind them, with disdain. And this phenomenon predates the recent decade of changes in work hours. The words “lazy,” “entitled,” and “uncommitted” have been used to describe those who followed in the training pathway for as long as any of us can remember. In an “Open Letter to My Elders,”1 Eric Biondi, an academic pediatrician in his first year as a faculty member at the University of Rochester, wrote: “We have so much to learn from you, the generations of physicians who came before us. … You are the keepers of the ideals of our medical forefathers, so pass those ideals on to us.” We take up Biondi’s challenge and expand it by creating an intergenerational dialogue. Each of us—a second-year internal medicine resident, a midcareer academic cardiologist, and a senior general internist—will offer 5 key messages we would like each other to hear.
Teach Me How to Manage Uncertainty and Failure
Residents are not accustomed to uncertainty or failure; in fact, many got to medical school by “being perfect.” However, in our training and careers, we will make mistakes, some of which will harm our patients. These experiences have the potential to erode our confidence. We need reminders that even our attending physicians don’t always know the answer and that sometimes even when we do our best we won’t succeed. Help Me Identify What Is, and Is Not, Important as I Make Choices That Shape My Future Career
Income, duration of training, competitiveness of fellowships, lifestyle, location, and availability of jobs are some of the factors that influence residents’ decisions about career choices. We need our mentors to help us identify which factors are short-sighted and which will be important in the future. Tell us how you made those choices: when you were right and when you were wrong. I Look to You for Inspiration
Medicine is a long road. But when attending physicians with whom we connect love their work, we know it is possible for us to be “like them” one day. So show us your passion; tell us what gets you out of bed in the morning.
Messages From a Midcareer Cardiologist Always See the Patient
With the advent of the electronic patient record, I have witnessed the comprehensive compilation of histories, physical examinations, and investigations as a trainee sits at a remote workstation far away from the patient bedside. One has to stand at the foot of many beds to develop “physician’s intuition,” which remains essential to the art of diagnosis.
Messages From a Resident I Want Medicine to Be Fun
Enthusiasm from teachers is infectious. Even rotations that require a heavy workload can be enjoyable if there is a positive team environment, teaching around cases, a sense of meaning in patient care, and acknowledgment of our hard work. When these conditions prevail, every member of the team wants to be present for patient care and learning; there is no place else we would rather be. Corresponding Author: Allan S. Detsky, MD, PhD (adetsky@mtsinai .on.ca). Section Editor: Roxanne K. Young, Associate Senior Editor. jama.com
I Need to Be Given Responsibility to Grow
Themostenjoyablerotationsinresidencyarethosewhere we are challenged to the limits of our capabilities to solve meaningful problems. Difficult situations can be stressful in the moment, but nothing compares to the satisfaction and personal growth we experience from handling
Spend Time With Your Patients, Even If There Isn’t Anything You Can Do
I learned the value of accompaniment from a young man I cared for in the worst days of the HIV-AIDS epidemic, who suffered torturous discomfort from Kaposi sarcoma despite palliation. I rounded on him every day, even if only for a few minutes, until he died. Moments later, his devoted sister thanked me for not abandoning her brother in his darkest days. Now seeing patients treated with highly active antiretroviral therapy, relatively unaffected by their HIV infection, I am a frontline witness to the revolutionary gains of medical science. Learn How to Accept Criticism
We care about your success. The most valuable clinical lessons for me occurred when I was told I had made, or (Reprinted) JAMA April 7, 2015 Volume 313, Number 13
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/11/2015
1319
Opinion A Piece of My Mind
was about to make, a poor decision. If you want to learn from me, then let me criticize you. You should be made aware when you are not meeting the high expectations we have as a profession. Great emphasis is now placed on teacher evaluations that empower students to anonymously and negatively label these behaviors as intimidating rather than authoritative. If you want to keep learning, then recognize the difference between feeling appropriately chastened and being inappropriately humiliated. Remember, excellent patient care is not always about you.
uncertainty. An important skill is the knowledge of when uncertainty is acceptable, and when it is not, requiring further immediate investigation. Another skill is getting patients to understand when it is in their best interests to stop looking for the cause of their symptoms and let time determine the outcome. I use this sentence frequently: “We have done many tests to figure out what is wrong and so far none of them have given us the answer. That is a good thing because some of those answers would not be the ones you would want to hear. So now, we are just going to pause and see how things develop over time. This is good news.”
How to Handle Work-Life Balance
It is easy to feel overwhelmed by our perceptions that we are not meeting the expectations of patients or our own families. I have found that the effort to maintain control is more exhausting than simply embracing the busyness of professional and family life. There is no perfect solution. However, in my opinion, compared with physicians of an earlier era, we have more control over how we spend our time than the vast majority of people. Don’t Take It Personally
As said by American author Ann Leckie, “Surely it isn’t illegal here to complain about young people these days? I had thought it a basic part of human nature, one of the few universally practiced human customs.”2 Indeed, the old will always criticize the young. I have no idea when I became “mid-career.” For years after I completed my residency, I perceived myself as youthful and close to the trainees. But I was wrong. One of life’s cruel truths is that everyone will be “older” one day, and you too will be cranky.
Messages From a Senior Internist The Importance of Continuity
Physicians who care for patients over long periods have the advantage of intimate knowledge of the reasons for and responses to the clinical decisions made in the course of their illnesses. In addition, long-term relationships allow for the building of trust and a sense of responsibility. Patients generally prefer to see the same physician instead of starting over with a new one. Try as much as you can to emulate the spirit of “one doctor, one patient” in the care you deliver by looking for opportunities to maintain continuity. Know When to Review Images and Pathology Yourself
When key clinical decisions depend on the nuanced interpretation of imaging and pathology findings, review those yourself with a radiologist or pathologist. Face-to-face communication between the clinician and radiologist or pathologist will more often than not yield insights for both parties that will improve the decisions you will make. Learn How to Deal With Uncertainty
There will be many times when you cannot make a diagnosis and the prognosis is not clear. A good clinician learns how to manage that Additional Contributions: We thank Victor Fuchs, PhD (Stanford University), and Stephen Gauthier, MD (University of Toronto), for commenting on an earlier draft. Neither was compensated for doing so.
1320
Patients Want Hope, and Sometimes Can’t Hear Bad News
Several years ago I made a diagnosis in a man that I knew meant he was going to suffer a long and painful death. I delivered the news to him and his wife. After he died in the manner I had predicted, his wife told someone I knew that I was the only doctor who was honest with them from the start. I asked him whether she appreciated my honesty and he answered, “No, she did not.” Patients and their families are always looking for hope. There is a time when honest appraisal is warranted, but recognize that, in addition to denial as a defense mechanism that prevents accepting bad news, you may well be resented for delivering it and may want to find a way to offer some hope, even if it is only temporary. Have a Family
During your entire career, there will be a lot of people who may remember you fondly, but at the end of the day, the people you are most likely to be able to count on are the members of your immediate family, so make sure you have one (no matter how you create it). For me, the most important and satisfying thing I did was to have and raise children, although I can’t promise that they will never be a source of angst. And remember, if you choose to do likewise, there is never a good time to start, so don’t put it off too long.
This exercise has been useful because it induced each of us— separated in age by almost 20-year intervals—to reflect on the important issues we feel should be communicated to other generations without presuming whose messages were most valid or important. We each wrote our sections without the knowledge of what the others would say; so it is not surprising that some of the messages have common themes (uncertainty, mistakes, personal life), while others are completely different. We can only wonder about the messages we might have received from the generations that preceded us, or ones we might receive from those that will follow us. But for now, we believe this intergenerational dialogue, which each of you can replicate in your own settings, forms the basis of an educational curriculum to help both young and old accept the inevitability of change, while simultaneously meeting Biondi’s plea to pass the ideals of medicine’s forefathers into the future.
1. Biondi E. In defense of my lazy and entitled generation: an open letter to my elders. Hosp Pediatr. 2013;3(1):76-78.
2. Leckie A. Ancillary Justice. New York, NY: Orbit US; 2013.
JAMA April 7, 2015 Volume 313, Number 13 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/11/2015
jama.com
