Call of duty?

I was left flabbergasted after finding out that a number of medical interns/clerks abandoned their duty post to watch The Eras Tour. If you think it’s justifiable then maybe a career in medicine is not for you.”—@OB_wankenobiIt’s been a while since that tweet ignited a social media firestorm, alongside a memo from a medical school warning students that attendance to the concert “is not an acceptable reason to be absent” and is tantamount to “abandonment of post, even insubordination.” Many voiced the view that “interns and clerks deserve a life outside of medicine” and should be allowed to attend a concert—or any event for that matter, especially since internships and clerkships are actually “unpaid labor” for which the trainees must be the “primary beneficiary.” Others felt that responsibility matters: A hospital post is a commitment that cannot just be abandoned; medical training may be strict, but that’s because lives are at stake in medicine and we need doctors with teamwork, professionalism, and a strong sense of duty.

The furor has subsided, but I believe that it remains a teachable moment for the medical profession. Here are some of my “cold takes” on the matter:

First, I think we need to rethink the militaristic framework with which we have conceptualized medical training. The terms “duty,” “abandonment of post,” “insubordination” all point to this framework (thank you, Dakila Yee, for your tweet that called this to my attention), as well as the top-down, hierarchical system: We expect interns to be like those BTS members who join the Korean Army for a year, banished from concerts and public view.

There are some rationales to instilling this mindset: There are situations when you cannot second-guess a senior’s decisions, for instance, while in the operating room, or when there’s an emergency and there’s no time to debate the course of action. And of course, one does not have to be an intern or a resident to appreciate how the unannounced absence of a team member can be a major inconvenience.

But are there alternatives we have not considered? While the military model has been in place for decades, the question of whether it has actually worked well has been left unasked, let alone answered. Meanwhile, we know enough to be critical of its effects: To begin with, it has engendered a system of seniority that has not always translated to better outcomes, and it has done so at the expense of the mental health of so many trainees.

The final point bears reiterating: Every now and then, a resident or a medical student decides to end their own life, and the fact that we don’t have statistics of these suicides is a sign in itself of how the medical profession has failed its own people.

This conundrum, I must hasten to add, is true for many countries; my History of Science colleague Alexis Hatch, who studies physician suicides, tells me that it is just as understudied in America. But there might also be unique factors in the Philippines, such as the “moral masochism” that somehow makes “having fun”—e.g., going to a Taylor Swift concert or a hiking in the middle of the semester—something to be ashamed of, instead of being embraced as part of a balanced life.

Another necessary context is our structural human resources problem: Health-care workers are underpaid and overworked, just as hospitals are understaffed and overwhelmed. In fairness, we’ve come a long way from the time when medical training is even more laborious and militaristic, with 48- and 24-hour duties being (or at least becoming) a thing of the past. But medical training remains a contested ground with intense pressures and great expectations: from family members, seniors, colleagues, patients—and a long and expensive journey that’s filled with financial, professional, and moral uncertainty in the end.

One low-hanging fruit is providing more leaves—including “leaves for whatever reason”—for hospital staff, preemptively recognizing that there are inevitable moments that people need time off, if nothing else, for mental health, which translates to the health of staff and patients alike. For interns and clerks, these leaves can come in form of an easier scheme to move duty schedules (instead of having to informally do it like we used to)—as well as more electives throughout medical school. These (and students and staff themselves surely have better ideas) can go a long way toward the bigger goal of normalizing a culture where people are encouraged—not shamed—for enjoying life outside the hospital.

But if—as I suspect—the military model is at the root of this problem, then we must rethink its relevance for our time and revisit how it is reflected in medical education and culture. Although I share medical educators’ concern for instilling a deep sense of commitment and discipline from among their ranks, I think that commitment to other aspects of life does not preclude developing this ethos of duty.

Ultimately, we need to build a medical culture in which the ability to care—for our patients, for our students, for our staff—is seen not as a secondary to excellence, but its very definition.