Dr. Danny Panisko, Co-Director of the Master Teacher Program, teaching Department of Medicine residents.
A couple of weeks ago, I attended the annual international osteoarthritis research society meeting. In catching up with my international clinical colleagues, many of whom hold medicine leadership roles at their universities, a common concern emerged: that medical residency in 2024 might be falling short on preparing learners to meet current and future societal healthcare needs.
Population aging and rising prevalence of many chronic disease risk factors have increased the need for longitudinal chronic disease prevention and management, and complex shared patient-clinician decision making in an increasingly strained healthcare system. People with chronic conditions represent most people presenting to the emergency rooms and admitted to in-patient beds across our hospitals. These people – our patients – need our care 24x7. This is not new, but there are more of them, and their expectations are, on average, higher than their predecessors. They have access to the internet and with that comes information, both good and bad. All this to say that the demands on physicians in internal medicine and its specialties are greater now than ever. More technologies to learn, more administrative pressures, more complex procedures to perform.
Contemporaneously, much-needed efforts have been made to humanize the learner experience – and along with it, faculty members’ working lives too. These changes were needed if not overdue. We now talk about how to manage failure, uncertainty, and fatigue – emotions that are impossible to avoid in medicine – and provide time away from the clinical environment for a variety of reasons, including attendance at Academic Half Day, study for examinations, recovery post-call, and lieu days. While this is all reasonable, we need to ensure that residents are still spending enough time engaged in patient care activities to develop the skills they require. We also need to ensure that physician well-being is balanced with our core professional responsibility to place patients first.
More than a decade ago (August 2011), Dr. David McKnight, then Associate Dean, Equity & Professionalism at the Faculty of Medicine, entitled his remarks to the incoming MD students “It’s not about you.” He talked about trust and respect as at the core of professionalism: the importance of being worthy of the trust that patients, colleagues and even society will place in you as a physician. The importance of demonstrating respect – respect for patients and for the team you work with. He went on to say the following, and I quote:
“You are obviously bright and hard-working achievers. But that is not enough. You must always remember that it is never just about you. You are entering a profession where the needs of others must inform our actions. Sometimes that is called altruism. Altruism is often called one of the pillars of professionalism.
When a frightened parent brings a vomiting and lethargic infant to the emergency room in the middle of the night, that child’s welfare comes first, and the doctor gets out of bed. When a cardiologist’s clinic is finished and she plans to go to a concert, that plan will be set aside for an urgent patient. There is an old debate about who is the most important person in the operating room. Is it the surgeon, the so-called “captain of the ship?” No: clearly the most important person in the operating room is the patient.
You will hear much about the so-called Doctor-Patient relationship. I prefer to call it the Patient-Doctor relationship; it puts things in the right order. For when we lose sight of the reason we take up medicine we lose the essence of what we do. It’s not about us; it’s about the patients.”
When we become physicians, we declare that we “… shall not let any lesser public or professional consideration interfere with my primary commitment to provide the best and most appropriate care available to each of my patients.” Embedded in this oath is the concept of sacrifice – medicine requires personal sacrifice. Trust, respect, altruism, and sacrifice for our patients – these are the tenets of our profession. While each medicine specialty has its pros and cons, none is immune to these responsibilities.
Only through practice can clinical skills be truly learned and honed. Going forward, we need to ensure that our learners have every possible opportunity to interact with patients – speak to them, listen to their stories, examine them, care for them – to develop and sharpen the clinical and personal skills required of a physician. Not just have the opportunity, but are encouraged to take advantage of the opportunities, because these skills cannot be learned from didactic teaching or listening to a podcast. It happens in clinic, on the ward, in the ER. It happens while rounding with the attending at the bedside. It happens through observation of master clinicians’ interactions with their patients.
Last week, the DoM held its annual Story Slam with the theme “Filling Buckets.” Several residents told stories of what they had learned and how they had grown through their interactions with patients. Helping patients and seeing them through difficult moments, building relationships with them over the long term, and making a difference in their lives – this is the true joy of medicine.
Yes, our profession is hard work – challenging and exhausting. It requires sacrifice – patients’ needs will never align with typical workday or work week expectations. We need to acknowledge this and build the supports around us to enable us to meet the demands of this profession. It’s worth it.
