Response to
Being Well while Doing Well — Distinguishing Necessary from Unnecessary Discomfort in Training Lisa Rosenbaum, M.D.
AND
On Calling — From Privileged Professionals to Cogs of Capitalism? Lisa Rosenbaum, M.D.
The New England Journal of Medicine “MEDICINE AND SOCIETY”
As a leader in well-being, the commentaries by Dr. Rosenbaum resonated greatly with me. I’ve been particularly disheartened by the difficulty in engaging colleagues, especially trainees, in content and practices around well-being and resilience. These terms have become “trigger words” that are often immediately met with negativity and resistance. While a lot has been published on the need to address system drivers of dissatisfaction, and indeed this is important, I would argue that this doesn’t mean we should completely disregard individual well-being efforts. Dr. Rosenbaum’s commentaries hit the nail on the head with WHY there seems to be such a challenge engaging our trainees in individual well-being practices. At the core of individual well-being is the ability to identify personal values, articulate our purpose, find meaning in medicine, and connect to our calling. If those now practicing medicine indeed feel that the term “calling” “is weaponized against trainees as a means of subjugation— a way to force them to accept poor working conditions,” then the entire foundation of well-being is eroded. I think the antidote to this sentiment is well articulated by Rosenbaum’s reference to Maurice Mitchell’s words: “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.” Perhaps we need to step back and reframe our language and approach to well-being to address these issues that are getting in the way of moving the work forward. Additionally, Dr. Rosenbaum’s discussion around discerning the difference between moral injury and discomfort is important. She says “Having to admit a new patient right before end of shift is not a moral injury. And burnout is not the same as depression; the substantial proportion of medical students and trainees who have debilitating mental illness need adequate care, but we cannot help them — much less address our structural inadequacies — if differentiating between serious illness and the inevitable challenges of training is treated as a moral breach.”
I would like to delve into these concepts with our learners, the next generation of doctors. I want these people to strongly identify with their career choice as a calling, I want them to clearly be able to state their WHY of doing this work, to recognize those magical moments when their experiences and their values align, and see them energized by the kind of gratifying challenges that make up our practice in medicine. How can we start bridging this gap?
Dr. Rosenbaum’s commentaries
For medicine, an enterprise currently balancing
a crisis in well-being with the requisite rigors
of training and evolving workplace demands,
perhaps the biggest and most relevant expectation
Mitchell debunks is the belief that one’s “mental,
physical, and spiritual health is the responsibility
of the organization or collective space.” 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.”
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?
She seems unconvinced.
Instead, she wonders, “In a world infatuated
with victimhood, has trauma emerged as a
passport to status — our red badge of courage?”
Though Sehgal anticipates readers “grumbling”
about her questioning their traumas, she captures
the essential danger of this preoccupation. “The
enshrinement of testimony in all its guises,” she
writes, “elevated trauma from a sign of moral
defect to a source of moral authority, even a kind
of expertise.
Having to admit a new patient right before end
of shift is not a moral injury. And burnout is not
the same as depression; the substantial proportion
of medical students and trainees who have
debilitating mental illness5,6 need adequate care,
but we cannot help them — much less address
our structural inadequacies — if differentiating
between serious illness and the inevitable challenges
of training is treated as a moral breach.
Dr. W. wanted to suggest that there’s value in celebrating
excellence, while clarifying that the tweets
were merely a marketing tool, not meant as an
existential threat to trainee well-being. But before
he could, a resident commented that division
leadership would probably “gaslight everyone” by
saying exactly that.
But today, the one person posting
about a toxic work environment may be far
more influential than the quiet majority who are
learning and thriving.
Yet the mounting pressure
to project sensitivity to trainee well-being
has made it difficult to consider the consequences
of unwavering dedication to their comfort. Indeed,
emphasizing how critical it is for trainees to
become “comfortable with being uncomfortable,”
Dr. C. wondered, “If we keep going down this
rabbit hole, how can we become good doctors?”
Because measuring well-being is challenging, answering
these questions has never been easy. But now
merely asking them risks being seen as opposing
trainee well-being. The irony of these implicit
limits on discourse is that improving wellbeing
requires considering its meaning — and
therefore talking about it.