AMA Journal of Ethics^®

Countless stories about the experiences of those working, learning, and living within medicine's crucible are recounted and passed down from one generation of physicians to another. This crucible, otherwise known as internship, has often been characterized in military terms. Interns are seen as privates in boot camp, where their physical, mental, and emotional skills are pushed to the limits. Food rations and bunks are basic if not occasionally substandard. Many of the skirmishes and battles fought by interns are chronicled like wartime reports from the front lines. And, as in the military, a certain bond is established among physicians who live through the ordeal together.

While many of these boot camp analogies are right on target, the goals or ends of the 2 systems--one designed to train individuals who, in the act of defense, must sometimes do enormous harm, and the other designed to educate those who are expected to treat the sick with competency and compassion--differ greatly. The similarity of their means, however, creates circumstances in which the ends of medical education and training are oftentimes a casualty. Therefore, leaders in medical education and attending physicians (including myself) have a duty as teachers and mentors to address this system failure, even if it calls for random acts of kindness.

Though internship is now many years behind me, I still reflect on my experiences as an intern and wonder how things would have been different (or how I would have been different) if greater attention had been placed on sustaining the morale of interns, residents, and those around them. Many physician-educators have said that the toughening up process--being on call for 36 hours straight and seeing the course of disease through its initial acute phase--is a requirement of internship. Without it, these educators claim, one's ability to cope with the anxiety, frustration, and seeming chaos is undermined. While there may be some truth to that practical reasoning, many of the experiences of internship are unnecessarily exhausting and demoralizing. I would argue that the training and education of the next generation of physicians could be improved by giving greater consideration to the pivotal role that attending physicians play in setting the tone, spirit, and morale of the "troops" under their direction.

I am not suggesting that individual attending physicians can address all of the problems, especially the structural challenges, that confront academic medical centers in our changing health care marketplace^{1, 2, 3}. But I firmly believe that attending physicians must be keenly aware that their values and actions serve as powerful signals to others on the medical team. Our conduct at all times--and this includes the actions we take to bolster (or undermine) the morale of our students--sets important examples. I'm talking about simple, commonplace actions such as providing food for the team post call, something I make a point to do consistently. I have not yet had occasion to draw blood or insert an IV, but if my team needed an extra hand, I hope I would do it. At this point, I'm sure some of my colleagues are muttering to themselves, "Get a reality check."

Whether one considers such actions as placing an IV or offering food to be random acts of kindness is not the issue. The relevant issue is that, as teachers and mentors for the next generation of physicians, we must find our own practical ways to sustain the morale of our students. The why, what, and how is up to each attending physician, as random opportunities to act kindly present themselves. Sustaining sufficient morale among interns and residents strengthens the moral basis of professionalism and our ability to educate and train future physicians (some of whom may be taking care of us when we get older and sick) in the practice of ethical and compassionate medicine.

I would like to conclude by briefly touching on the "golden rule." As children, most of us learned about right and wrong, good and bad, and what constitutes proper conduct by reciting the golden rule: do unto others as you would have others do unto you. For many faiths and religions around the world, this ethic of reciprocity serves as the basis for moral and ethical conduct. In reflecting on the value of morale, all of us who are teachers of medicine should ask ourselves: If I were an intern again, how would I want to be treated by my attending? The teacher inspired by the ethic of reciprocity is not motivated by personal benefit. Those who will benefit will be the generation of students who have as their attending physicians the students we are now guiding and teaching. Ultimately, and more importantly, the beneficiaries of our attention to the morale of the learning environment will be the current and future patients of our students. I firmly believe the simple wisdom of this ethic of reciprocity is a key to educating for professionalism.