AMA Journal of Ethics^®

Each generation of physicians passes down countless stories about the experiences of working, learning, and living within medicine's crucible. This crucible, otherwise known as internship, is often described in military terms with interns as privates in boot camp, their physical, mental, and emotional skills pushed to the limits. Food rations and bunks are basic if not occasionally substandard; and many of the skirmishes and battles fought by interns are chronicled like wartime reports from the front lines. 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 on target, the goals of military and medical training are very different; one system training individuals to do enormous harm, if necessary, and the other teaching students to treat the sick with competency and compassion. The boot-camp atmosphere of the internship year, however, often creates circumstances in which the ends of medical education—producing competent and caring physicians—become a casualty. Leaders in medical education and attending physicians (including myself) have a duty as teachers and mentors to bolster the morale of young physicians in their internship years with 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 there had been greater attention to sustaining the morale of interns, residents, and those around them. Many physician-educators have said that being on-call for 36 hours straight and seeing the disease through its initial acute phase is a requirement of internship; it toughens you. Without it, these educators claim, one's ability to cope with the anxiety, frustration, and seeming chaos is undermined. There may be some truth to that practical reasoning, but many of the internship experiences are unnecessarily exhausting and demoralizing. I would argue that the training and education of the next generation of physicians would be improved if attending physicians were to give greater consideration to their role in setting the tone and encouraging the spirit and morale of their "troops."

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.^1-3 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 and our actions to bolster (or undermine) the morale of our students set important examples. I'm talking about simple actions such as providing food for the team post-call, something I make a point to do consistently, or drawing blood or inserting an IV if my team were to need an extra hand. 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 for acts of kindness present themselves. Sustaining morale among interns and residents strengthens the moral basis of professionalism and our ability to educate and train future physicians 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 tenor 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.