Two consecutive editorials in The New England Journal of Medicine of March 11 address an issue I have long contemplated. In effect, is medicine the exclusive province of the seemingly whole or is there room for the disabled and mentally imperfect? The editorials make a strong case for inclusivity and for changes in the medical training system to adopt it for those with physical disabilities and mental illness. Among the suggestions were the identification of a Disability Service Provider for medical students and trainees needing help negotiating the rigors of medical training and their own personal limits, easy means of disclosing to those who need to know (and not to those who don’t) what those limits might be, and making clear what the expectations of any clerkship or rotation are before the rotation starts.
All of this came as an amazing shock to me. Why? Because when I trained all those years ago, no one cared about any physical or mental issues one brought to one’s training. In essence, at Duke, the mantra was clear. Tough it out or as we liked to say, “I know life is hard, but what did the Gram stain show?”
I am quite sure that is no longer the case at Duke, but here’s my dilemma. That rigorous training that I withstood—sometimes more successfully than at other times—served me well in emergency rooms and cancer wards years after the training was over. Whether it was diagnosing Von Recklinhausen’s Disease in the middle of the night at a community ER while moonlighting or packing the nose of a bleeding leukemic at the National Cancer Institute when there were no otolaryngologists on staff, the Duke training of being alone, at night, and being the only thing between a sick patient and disaster served me well.
What’s the proper balance between a boot camp mentality and politically correct compassion?
These editorials make it clear that such a place exists. There is not only a place for the disabled and those with mental illness in medicine, it is desirable that all people be recruited for they have something to add that others might not. It is not hard to see that. Those with disabilities can do the work and can bring a sensitivity to the pain and disability of others that the abled may not. As someone who has experienced the pangs of depression, it was only after that experience that I better understood what non-physical disability and pain is all about.
Let’s also be clear. The number of students and trainees who experience abnormal stress, sleep disturbance and other forms of mental illness is probably far higher than the 4.9% reported. I doubt any clinician in the age of covid escaped unscathed from the disorienting drama of death and despair inflicted by the pandemic. Recent episodes of New Amsterdam, an NBC television series, have done a masterful job of depicting the effects of the virus on the staff and patients of a large public New York City hospital. At one point, everyone was severely affected by the pandemic.
This life we physicians have chosen is a tough one. When I trained, it was like boot camp or more like SEAL team training and no one wanted to ring the bell. If you were collapsing physically or mentally, you kept it quiet for fear of being thrown out of the club you had already worked so hard to join.
Things are different now. Every doc does not have to be a white, male, able-bodied, mentally calm and focused individual with sterling recommendations and high grades. There is room for everyone in medicine and the need is greater than ever.
Just as we have ramps to accommodate wheel chairs in public spaces, we need ways to accommodate the needs of the less abled and psychologically challenged in medicine.
I don’t have my answer as to where the balance lies between boot camp and accommodation. I do believe that such a balance exists and we must strive to find it. Medicine will be the better for being open to everyone—especially now when we need more practitioners with empathy, compassion and broad life experiences to effectively deliver care to everyone.