A Letter to Our New Interns

By Rachel Conrad, M.D.
Child and Adolescent Psychiatrist at Brigham and Women's Hospital
Instructor in the Department of Psychiatry at Harvard Medical School
Faculty in Medical Ethics and Professionalism at Harvard Medical School

 

Rachel ConradAmong the many Osler quotes that you will hear during training, these words might resonate in our current moment: “Humanity has but three great enemies: fever, famine, and war; of these by far the greatest, by far the most terrible, is fever.”1

We are living, working, and training in one of the most complex and uncertain times known to our profession in recent history. Our profession has not encountered such tragedy since the world wars or the Influenza of 1918.2

In past years, you watched as upperclassmen radiated excitement on their Match Day, which is often more regaled than graduation and may be medicine’s equivalent of a coronation. Students, friends, families, classmates, and faculty hug and cry en masse during the celebration. Four years of struggle paid off as students opened envelopes divulging the next leg of their journey. You are chosen! You, unfortunately, did not have the opportunity to celebrate on Match Day nor graduation sharing the same carefree joy and triumph with friends and family. Your days of celebration were shadowed by your upcoming role as a doctor and healer amid a pandemic.

During the COVID-19 pandemic, the simultaneously overwhelming demands of intern year and the current risks placed on physicians are unprecedented. This may pull us along two axes: a duty to serve3 and an innate impulse for self-protection.

This tension has been and will continue to cause a conflict in your life as a physician. Early in the surge, our colleagues went to work with the uncertainty of sufficient PPE and facing the risk of transmitting disease to their loved ones. As an intern many years ago, I remember wondering whether I had time for a quick bathroom break without compromising the moments that I might have to spend with a patient. Dilemmas like these are normal in our day to day life: Am I doing enough? Am I doing enough good?

Our responsibility to our patients may sometimes be at odds with our own needs for self-compassion, self-kindness and self-care. Our system continuously pushes us towards briefer, more transactional interactions with patients, dehumanizing the doctor-patient relationship, exploiting our generosity,4alienating physicians,5 and, ultimately, risking disengagement6 and burnout7 among physicians. We simultaneously feel joy and fulfillment when connecting with patients as well as vicarious trauma, grief, and exhaustion while treading the waters of the unending task lists bestowed by our current healthcare system.

We envision ourselves as physicians who are present, calm, and thoughtful, but there will inevitably be moments when we have our own needs. If we rush to the rescue every single time, we can become exhausted, burnt out, sick, or cynical. Moral distress8 emerges when we cannot align our actions with our deepest values. Sometimes we must protect or care for ourselves and our own bodies,9 balancing compassion for ourselves with compassion for our patients.

We often ask ourselves: How much do I give of myself? When do I contribute, and when do I hold back?

But we should be asking: Do our healthcare systems have a duty to physicians10 and specifically, training physicians? How can our systems best protect training physicians from unreasonable risks?11 When is a physician’s self-interest legitimate?12

I want to tell you that there is no easy escape from these struggles, and these questions are essential to your professional and personal journey. These questions make us better physicians. We each must strive to develop our own capacities for attunement to our own needs-- introspection about our own sense of meaning and thoughtful deliberation when we encounter competing demands or unreasonable risks.

I wish you each a long and happy professional life. I look forward to working alongside you and seeing your impact on our field. Despite the present obstacles to staying human in medicine, and the incredible suffering and tragedy that we each encounter, this is still most certainly the best profession.

Welcome. We are so lucky to have you!

References

1. Osler W. The study of the fevers of the South. Journal of the American Medical Association. 1896 May 23;26(21):999-1004.

2. Esler DJ. Whatever is Popular is Wrong and Other Pandemic Reflections. April 2020 BCMJ;62(3):85-86.

3. Brody H, Avery EN. Medicine's duty to treat pandemic illness: solidarity and vulnerability. Hastings center report. 2009 Jan 2;39(1):40-8.

4. Ofri D. The business of health care depends on exploiting doctors and nurses. New York Times. 2019 Jun;8.

5. Chervenak FA, McCullough LB. Academic physicians as factory workers: identifying and preventing alienation of labor. American journal of obstetrics and gynecology. 2019 Jun 1;220(6):558-61.

6. Yanchus NJ, Carameli KA, Ramsel D, Osatuke K. How to make a job more than just a paycheck: Understanding physician disengagement. Health care management review. 2020 Jul 1;45(3):245-54.

7. Helfrich CD, Simonetti JA, Clinton WL, Wood GB, Taylor L, Schectman G, Stark R, Rubenstein LV, Fihn SD, Nelson KM. The association of team-specific workload and staffing with odds of burnout among VA primary care team members. Journal of general internal medicine. 2017 Jul 1;32(7):760-6.

8. Berg S. 4 ways COVID-19 is causing moral distress among physicians. Jun 18, 2020. Available at https://www.ama-assn.org/practice-management/physician-health/4-ways-covid-19-causing-moral-distress-among-physicians (accessed 8/17/20).

9. Rosenbaum L. Once Upon a Time… the Hero Sheltered in Place. New England Journal of Medicine. 2020 May 6.

10. McCullough LB, Coverdale JH, Chervenak FA. Trustworthiness and professionalism in academic medicine. Academic Medicine. 2020 Jun 1;95(6):828-32.

11. McCullough LB, Coverdale J, Chervenak FA. Teaching Professional Formation in Response to the COVID-19 Pandemic. Academic Medicine. 2020 Apr 22.

12. McCullough LB. The physician's virtues and legitimate self-interest in the patient-physician contract. The Mount Sinai journal of medicine, Ne