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In General, We Are Defined More by Our Response to Defeat, Than the Defeat Itself

  • Daniel M. Gelfman
    Correspondence
    Requests for reprints should be addressed to Daniel M. Gelfman, MD, FACP, FACC, Clinical Professor Emeritus of Medicine, Department of Medicine, Marian University College of Osteopathic Medicine, 3200 Cold Spring Road, Indianapolis, IN 46222.
    Affiliations
    Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Ind
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      A recent review article in The American Journal of Medicine discusses physician stress and burnout due to physician occupational dissatisfaction.
      • Yates SW
      Physician stress and burnout.
      It discusses etiologies and offers solutions. Key points of the article are that physicians need to take better care of themselves; good medical care is dependent on healthy caregivers; the medical system we practice in currently creates much of physicians’ stress; and the difficulty physicians face when obtaining psychological assistance, as the need for this is stigmatized. The article speaks of the imperative for finding new solutions. Unfortunately, the widespread dissatisfaction physicians feel in our current health care system continues to persist. This commentary discusses conceptual issues in the culture of medicine that hinder change and improvement.
      The current culture in medicine unreasonably expects perfection, with only good patient outcomes.
      • Robertson JJ
      • Long B
      Medicine's shame problem.
      While sounding noble, this expectation undermines physicians, as it is overly simplistic. It is based on erroneous beliefs that good physicians can never be wrong, and that any patient outcome is due to the physician, alone. Recent commentaries in The American Journal of Medicine have laid the framework for recognizing the illogical nature of these statements. These articles discuss the difficulties in diagnosing and treating patients given the inherent probabilistic nature of medicine.
      • Gelfman DM
      ‘Good (medical) judgment comes from experience, and experience comes from (medical) misfortune’.
      They also speak of several of the qualities that are required in being a good physician, and one of these qualities unexpectedly reveals the existence of problems. Key qualities of good practitioners of medicine discussed include: kindness, empathy, intelligence, and courage.
      • Alpert JS
      • Frishman WH
      The most important qualities for the good doctor.
      ,
      • Gelfman DM
      When less is more, a caring physician's dilemma.
      On reflection, the last quality raises an interesting question. Most would think the practice of medicine requires confidence obtained from good training and experience, not courage (excluding working in the face of physical danger, as in the current pandemic). Why is courage and not simply confidence required?
      Courage is required because with experience, a physician's own vulnerability becomes evident. We know that bad outcomes will occur; it is just a matter of time. I remember being told this by a sagacious older physician on a community outreach medical school rotation in a remote town in Wisconsin back in the late 1970s. He told me this after I successfully performed some medical procedure under direction. He said that one will eventually see all the complications of any procedure, if done frequently enough. What he didn't speak about, as it wasn't so common then, was that bad outcomes or complications may result in public criticism. Most would agree that public criticism is best avoided. Somehow, we believe that physicians are rated as either good or bad, and good physicians should not be the subject of criticism. With one bad public outcome, one's image and perceived value can change. Intellectually, we know this isn't true.
      • Gelfman DM
      ‘Good (medical) judgment comes from experience, and experience comes from (medical) misfortune’.
      But this belief appears to be present in many physicians, at least subconsciously. I was reminded of this when I saw a recent editorial in the American Journal of Cardiology entitled, “You Are Defined More by Your Defeats than Your Victories.”
      • Doroghazi RM
      “You are defined more by your defeats than by your victories”.
      After reading this, recalling the behavior of many physicians, and looking at the medical literature; I realized how many physicians believe, at some level, that their perceived value is somewhat fragile and that it requires constant protection. This is not surprising, given the description in the literature of a hidden curriculum in undergraduate and graduate medical education. Part of the hidden curriculum is to convey a hierarchy in medicine, and this is accomplished by intimidation and shaming.
      • Robertson JJ
      • Long B
      Medicine's shame problem.
      One result of shaming is instilling the idea that if one appears to be wrong, one's value decreases. So, we learn that our decisions must always appear to be right in order to constantly prove our worth. This does have a benefit of preventing physicians from feeling that they can do anything and not be answerable to others. Clearly, there must be justification for our actions as physicians. However, overemphasis on making everything look good and be defensible distracts us from our purpose of proper patient care, and it is exhausting. How can we expect physicians to practice with compassion and excellence in the current complex environment, especially in difficult situations, if they themselves feel under threat and are distracted?
      Some may actually wonder what is wrong with an all-or-nothing approach, as discussed in the AJC editorial.
      • Doroghazi RM
      “You are defined more by your defeats than by your victories”.
      The editorial warns us to try to avoid taking chances and play it safe, lest we expose ourselves to embarrassment, which can have devastating emotional consequences. We are given the example of the stockbroker who commits suicide in response to bankruptcy. Unfortunately, always playing it safe hampers one's ability to practice medicine well. It tends to shift the physician's focus on how things look, away from the patient or problem. This fatiguing cognition is often going on while one is trying to treat patients. The net effect is excessive testing to avoid any criticism
      • Gelfman DM
      When less is more, a caring physician's dilemma.
      and burnout,
      • Robertson JJ
      • Long B
      Medicine's shame problem.
      ,
      • Drummond D
      Physician burnout: its origin, symptoms, and five main causes.
      the opposite of our often-stated goals.
      There is a more subtle problem with the victory vs defeat approach to the practice of medicine; it implies that physicians practice medicine alone. Medicine is best practiced as a team. Every member of the team brings something to the table. For instance, the added value of the judgment, both medical and nonmedical, of highly trained members of the team, such as nurses, pharmacists, social workers, or therapists, cannot be overemphasized. By understanding this and working using a team approach, one can be a more effective practitioner. Even if not acknowledged, patient outcome is still dependent on many individuals other than the physician. A simple example is the time required for a patient to receive a medication after an order is written.
      Interestingly, this all-or-nothing approach to success in life has been the subject of much literature. Rudyard Kipling's poem, “If,” discusses this topic. This is most poignant in the following excerpt:If you can meet with triumph and disasterAnd treat those two imposters just the same …
      Kipling so clearly sums up the truth that the measure of one's impact in life is very complex and not easily measured.
      We need to shift our focus in medical practice back to what is important. Medical practice does involve solving complex medical problems and performing difficult procedures. Some of this is accomplished working alone, in a team setting. And we are naturally upset when things don't go well. But, as individuals, we should remember our value is not based on each victory or defeat. We need to learn from poor outcomes, but not dwell on them excessively. In general, we are defined more by our response to defeat than the defeat itself. Focusing mainly on defeat simply makes us weaker and distracts us from the purpose and the enjoyment of medical practice. And this fuels burnout. The enduring joy we experience in the practice of medicine comes less from victories and more from our relationships with colleagues and patients who are our friends, and who validate our competence by giving us their trust.
      • Gelfman DM
      Thank you for letting me be your physician.

      References

        • Yates SW
        Physician stress and burnout.
        Am J Med. 2020; 133: 160-164
        • Robertson JJ
        • Long B
        Medicine's shame problem.
        J Emerg Med. 2019; 57: 329-338
        • Gelfman DM
        ‘Good (medical) judgment comes from experience, and experience comes from (medical) misfortune’.
        Am J Med. 2020; 133: 1374-1375
        • Alpert JS
        • Frishman WH
        The most important qualities for the good doctor.
        Am J Med. Nov 11 2020; ([online ahead of print])https://doi.org/10.1016/j.amjmed.2020.11.002
        • Gelfman DM
        When less is more, a caring physician's dilemma.
        Am J Med. 2021; 134: 561-562https://doi.org/10.1016/j.amjmed.2020.12.014
        • Doroghazi RM
        “You are defined more by your defeats than by your victories”.
        Am J Cardiol. 2021; 139: 131
        • Drummond D
        Physician burnout: its origin, symptoms, and five main causes.
        Fam Pract Manag. 2015; 22: 42-47
        • Gelfman DM
        Thank you for letting me be your physician.
        Patient Educ Couns. February 8 2021; ([online ahead of print])https://doi.org/10.1016/j.pec.2021.02.015