COMMENTARY

Doctors: Our Culture Is Ours and We Need to Own It

Rana L. Awdish, MD, MS

Disclosures

November 24, 2020

Rana L. Awdish, MD, MS

Healthcare as an industry depends on the altruism of its doctors and nurses — and we willingly give of ourselves each day, prioritizing patient needs above our own. To honor this, organizations should aspire to be as generous as their workers. But we'd be wrong to lay the responsibility for our actions entirely in the hands of our employers.

As a critical care physician and an author who works in the area of culture change, I'm keenly aware that our sense of professionalism, duty, and identity contribute to our own moral distress. Much hinges on identity formation, a process that begins early and is remarkably consistent, no matter where we are trained.

My first awareness of this issue came during my third year of medical school. I was assisting in a particularly long renal transplant surgery when I became dizzy and nearly fell backward off my step stool. As a short, brown woman, I already didn't match the dominant culture of the operating room. By nearly fainting, I had succeeded in demonstrating vulnerability which made me unworthy of even holding a retractor.

The grizzled attending glared at me across the table and unexpectedly asked, "Have you spent much time studying the ancient Greeks?"

I shook my head, "No."

"So then you don't know about Prometheus. Prometheus stole fire from the gods and delivered it to humans to allow self-efficacy. Tell her what happened to Prometheus," he gestured to his fellow.

"It made Zeus angry, so he chained Prometheus to a cliff, where a vulture tore out his liver and ate it. Each night his liver regenerated, and he'd be attacked again," the fellow reported.

"And yet," the surgeon resumed his storytelling, "though Prometheus was prescribed a fate of perpetual agony, he never expressed regret. He was resilient even in the face of his own oppression. We too should be resilient even when in agony," he instructed before adding, "It's who we are."

The subtext was, "Is it who you are?"

To be honest, I wasn't sure. What I knew was that I found it difficult to stand solidly when dizzy and dehydrated. In the end, I endured the 6-hour surgery. I was spurred on by a sense of shame and obligation, but also by a desire to prove that despite outward appearances, maybe I did belong.

That surgeon more deliberately articulated what would be more subtly suggested throughout my training. Medicine would require that I surrender my old self in stages and reimagine a different identity. Unlike many professions, my utility would not be judged solely upon the effort I expended, or what I produced, but also on my ability to internalize medicine's definition of professionalism and the expectations conferred by the words "It's who we are."

And though we're still unpacking the way in which those words were historically gendered and racialized, I now know some things that I couldn't have known then. Namely, that it's a brilliant organizational strategy. Identity is the ideal motivator if you need to exact an impossible standard. Conscience is the ideal weapon for conformity to the ideals of a profession.

We don't require sleep and can go long periods of time without eating.

We exist to care for our patients, and of course that requires sacrifice.

Even if we are berated, sexualized, marginalized, or shamed, we will retain our composure.

Being able to achieve and maintain a certain level of performance, under any circumstances, and regardless of obstacles, is the verbalized norm.

We would internalize the expectations of our training as a moral obligation. I owe it to the patient. We would believe the myth of vocation. I was called to do this work. We would fetishize the suffering. Being on call for 36 hours teaches you to think on your feet.

The more we conformed to the norms and achieved seemingly impossible standards, the more external validation and affirmation we received that we belonged — and, perhaps more damning, the more our new self-image became an established reality. Then in the ultimate cultural chess move, the aspirational standard became a surrogate for our own conscience. What kind of a doctor would be fearful of their own patient? As if by magic, our new identity allowed us to rationalize what would never stand in another industry.

And it worked pretty well, before COVID-19. With the onset of the pandemic, demands escalated relentlessly and exposed how little room we had left to sacrifice. Though we were used to doing "the right thing," even at high personal cost, we began to wonder whether our altruism was being leveraged against us. Many of us found ourselves in a position of being constantly asked to sacrifice more.

We will sleep in basements and tents in the garage to protect our family from the virus. We will send our children away to live with relatives.

We will find a way to care for the patients, regardless of circumstances. We will reuse the scarce PPE.

We will stand vigil; we will be surrogates for the families that are excluded from the units.

We will bear the crushing weight and responsibility of caring for our own.

What's very clear 8 months into the pandemic is that our collective, constructed identities are not sustainable. We followed resilience to its natural end and found a kind of laxity there that is unstable and simply can't support our weight. It's time we step back from the notion of resilience as an individual trait and see it as an attribute of an organization and honor the belief that we can reshape the culture from within. It's far past time to examine the ways in which we used the concept of "professionalism" when we meant "conformity."

We may be fated to endure significant hardship in the coming months, but we needn't contribute to our own oppression. We can't simply accept being chained to the cliff, hoping we can regenerate enough of ourselves overnight to endure another day.

Because what I most want to tell that medical student in the operating room is that the real myth was not about Prometheus and the gift of fire. The real myth was believing that complete spiritual and bodily self-sacrifice is necessary to have a career in medicine, when the truth is, medicine is a place where we can do the work and remain authentic and whole — but only if we are brave enough to reshape it in our image.

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