Danielle B. Cross, MD, MS

There’s a phenomenon, or more like a belief, in medical training that “more suffering makes for better doctors.” As a result, we tend to compare ourselves to each other in the worst possible ways. Per this belief system, suffering is character-building, so who wouldn’t want to demonstrate that they excel in this area?

A friend of mine still tells a story from when I was a medical student on a sub-internship, back when I considered becoming a surgeon. We all understood the purpose of the rotation to be an opportunity to prove yourself. It’s hilarious that it could ever be interpreted to amount to more than that, especially given the increasingly bumper-rail environment created for medical students. As a student in surgery, you legitimately can only slow down the people you admire and work with. From that perspective, I remember everyone who ever mentored me in a clinical setting in an increasingly fond and appreciative way. During that rotation I was set on being tough as nails, or at least coming off that way.

As a sub-intern, there are no set limits on on-duty hours. I think that’s largely because you aren’t contributing much. Too few hours or too many…it doesn’t help or hurt any patients, which was ostensibly the goal of work-hour restrictions at the outset. As a student, you hope the experience provides insight into your future life as a resident. At some point, I was scheduled for a 24-hour shift. The first 20 hours passed pretty uneventfully. Morning rounds came and went the next day as expected. Then my real adventure began. After walk rounds with the team, a senior resident looked in my direction and commented that “there’s a cool case starting now, you should check it out.” Understanding what I know now, there were infinitely fewer people tracking my sleep than I initially thought. It seems unlikely that this resident had any awareness at all of what my recent schedule had been. That being said, lots of people just get ignored so I was grateful for someone to be thinking of me and suggesting anything.

Understanding that you pretty much never say “no thanks” during one of these rotations, I eagerly made my way to the OR. At the time, the trip to the operating room still held a magical appeal to me. Wearing scrubs even today, by regulation, is still enough to keep me in good spirits through almost any experience. I mean when else do you get to wear functional pajamas to work? Walking to the OR, alone or as part of a group, only added to the highs as compared to the lows of the rotation. Knowing where to go, knowing what to do, knowing who to talk to are all things that no one can know prior to their clinical rotations. Like anatomy lab, it’s an experience that feels quintessentially doctor-ish, so I cherished the feeling of being part of the club.

I made my way to the OR for a case that ended up lasting several hours. By that time, I had made friends of the scrub nurses and managed to avoid any major screw-ups, so my time in the OR was more or less enjoyable rather than arduous. My story really starts after that. Once the morning case wrapped up and I was washing my hands outside the proper OR suite, a senior resident approached me and casually suggested that I report to the other, different hospital for an early afternoon case. That kind of suggestion wasn’t within the course of a normal day so it was clearly in the realm of a challenge. After all, I could leave. I could go home. No one would dare question that choice. After all, I had just been pretending to be a doctor for approximately 30 hours.

What followed was a test of will and attention. Cloaked from thyroid to ovaries in protective lead, I observed, and contributed nothing, to a spinal case with a 5-inch field. The lead was shockingly warm--like heavy insulation in the otherwise chilled room. A warm, heavy blanket reminiscent of something I would curl up under on a coId night. To add to the drama, as I am quite short, I was perched on top of a medical-grade stool so I could theoretically see what was happening a few inches down into the five-inch sterile opening. I remember pinching myself on the arm to stay awake. And when that didn’t work, fear of falling into the field held me upright.

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Several hours later I was outside washing my hands again, impressively lucid and able to participate in the conversation. I was approaching hour 37 of being in the hospital when one of the chief residents who had participated in the case looked at me and with sincere curiosity asked, “How are you awake?” I shrugged, unable to answer how my brain did what I recognize now as flipping the lights on inside my head upon independently recognizing that the sun was up so it was time to continue on with the new day. He sent me home shortly after.

My friend tells this story to other people all the time. She’s genuinely proud that she saw me later that evening, around hour 40 of being awake, for a brief dinner. I didn’t say much other than to make excuses for being a bad dinner partner. In the course of explaining that I’d been awake since the prior pre-dawn hours, what she heard was a war story; something that inspired pride and was meant to be shared. Something other people, herself included, thought she could never do.

Knowing myself and how I came to be awake that long, I knew it wasn’t true. There was nothing special about keeping your eyes open. Under the right stress, anyone could and would do it. If anything it probably just said more about the level of stress I was able to achieve. Ironically, my friends who fell asleep in the same situation were the ones who went on to become surgeons.

Now, I always cringe a bit when my friend tells this story. There’s no need to compare ourselves to each other by focusing on the inhumane parts of the job. It does and always has felt like a race to the bottom. Who benefits from competing to win the competition for most sleep-deprived, the most abused, the most miserable? I’m happy to say that I can recognize that I am not, and don’t aspire to be, any of those things.

However, when I started residency, I was a big part of this culture. It’s all I really knew and was the only way I knew how to connect with people around me going through the same thing. I stopped piling on when I realized how it affected my views of my colleagues from other specialties. You see, the mindset of those inclined to be miserable engenders contempt and narcissism; the kind of absurd thoughts that everyone else isn’t working hard or worse, is just lazy.

The idea that everyone around you is working to capacity may at first seem depressing, but there’s actually a lot of camaraderie lurking just below the surface in the hospital.

In reality, we never know what’s going on in other people’s lives or what their job demands of them. Like anything, my contribution to this culture was easier to hear when the same beliefs were spouted from the mouths of other people around me. I realized how ridiculous it was to assume that any other trainee wasn’t also being stretched to their limit. Then I realized it wasn’t just the residents; other hospital staff and ancillary workers were all in the same boat.

Once I opened my eyes, I saw the challenges the nurses deal with without ever bringing it to our doorstep. I also saw the miracles that our social worker seemingly conjured from thin air. Simply put, I became more appreciative of everyone around me.

A little empathy, a little benefit of the doubt. That’s all I needed. When I learned that about myself, I started loving everything about being a doctor. After all, it’s kind of amazing to be surrounded by so many people that are so dedicated to their work.

I don’t often see the world through rose-colored glasses, so this change in mentality surprised even me. I found it metastasized to other areas of my life without effort. I could see that my patients, like everyone I worked with, were also just trying to get by while doing their best. Kind of like when you first see your teacher in regular clothes at the grocery store--an 'aha' moment that seems juvenile and obvious in retrospect.

This discussion will eventually lead to a discussion about resilience and why it’s such a toxic idea. But before we get to that, I think we have to first address the false idea that so many of us have or still hold about the merit of suffering. Not only should we not have to suffer, but we shouldn’t impose the expectation of trial and tribulation on others either.

I can’t pretend that I don’t enjoy pride, whether it originates in me or my friends and family. I just disagree with what should be a source of pride. I would argue that viewing adversity for the individual as likely positive in the long run is a set up for the inevitable misery of the many. I can say that because I distinguish between hard work and what feels like pointless hardship. In this story, I would feel differently about the same set of facts if I had contributed something during all of my legendary 40-hour shift (an exaggeration that my friend has maintained over the years attributed to creative license). As a resident, I’ve had plenty of 30-plus hour days that brought some real fulfillment entirely because of what I did during those hours--not just due to the number of hours.

This blog has been reposted with permission from amillenialmd.com.

Are you a neurology resident or fellow? Share your clinical experiences, tips for work-life balance, and career advice on NeurologyLive's Fellows' Corner. 

Danielle B. Cross. MD, MS, is a neurology resident in training with interests in vascular neurology, technology, diversity and inclusion, and education. She has previously taken time away from medical education to work in a small medical startup where she became a believer in work-life balance. She looks forward to fellowship and plans to continue contributing to her blog, 

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Everyone Is Working Hard: Why Shift Work Shouldn't Be Celebrated

Humble pie is best when left to sit out, unmolested, for several hours or possibly even several days. Like a soufflé, timing is everything. What’s it made of? Well, the ingredients are simple:

Humble pie is an acquired taste. It’s as mandatory a part of the diet of any well-meaning clinician as vegetables so it is incumbent on us to learn how to consume it gracefully and with minimal tears or defensiveness. Some learn this skill sooner than others. Some fight the inevitable and believe they can overcome this doctor vitamin with greater ego or more book smarts.

It’s true that more experience and greater comfort with clinical evidence can reduce the amount of humble pie one is required to eat. However, upon reviewing the ingredients list, you’ll see that it is impossible to avoid cooking up a batch occasionally. Doctors are afflicted with ego as a rule, so it’s only a matter of how much we bring to the baking counter that determines how much pie gets made.

Most important about this concept is the understanding that we are not in control of this kitchen. While only a sprinkle of clinical ambiguity is required to start out a batch of humble pie, we can rarely anticipate how much our environment has in store for us.

I have to admit that circumstances have occasionally conspired to allow me to enjoy watching someone else eat humble pie, a little more than I should have. I imagine being a senior resident is like being an older sibling. There are some lessons you know your juniors have to learn for themselves, and as long as it doesn’t hurt anyone, letting them learn the hard way is sometimes the most effective method.

Recently I was pacing the halls of the outpatient clinic, waiting for my first patient to arrive. I’ve always been a pacer. As a child I loved horses; racehorses in particular, before I learned about the awful conditions many endure without ever winning on the track. They always looked so beautiful, stretching out longer than their body length in a full-on gallop. Before the starting bell ever rings, there is always a profile view of all the horses confined to their temporary stalls associated with their starting positions. Some of the horses would stand calmly while others danced in place. I always understood those horses, fidgeting in place without purpose. Antsy to just get to it.

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I saw a patient that was known to our clinic but not to me personally. She had some abnormal findings on her exam and likely needed more diagnostic studies. As I was staffing the case with my attending, I observed for the first time someone who had reached nirvana level comfort with humble pie.

“We don’t know anything!” she said as she threw both her hands above her head. That was maybe the most reassuring thing I’ve ever heard from the mouth of an attending. Certainty from someone more experienced and more knowledgeable than you’ll ever be doesn’t really inspire warmth. It’s just the status quo. Uncertainty from someone you look up to has more value than any number of years of reassuring words or pats on the back. I was used to the feeling that 

But to hear it from her made that reality seem tolerable. Normal even. We brainstormed about how to proceed until we came up with what seemed like a reasonable plan.

Comfort with the unknown is ironically something that helps minimize the size of the humble pie. There’s no benefit to testing for 

 as eventually, something will return with an abnormal result. That’s just simple statistics. However, there is value in keeping the door to other possibilities open. To keeping an open mind.

To be honest, my patients seem to like the appropriate show of uncertainty as well. They are savvy people and are well aware of when there is more than a sprinkle of ambiguity in their case. This is where the art of eating humble pie enters. At some point, we are all wrong. Experience teaches you it is only a matter of time. How you deal with wrongness isn’t necessarily a given.

My program has recognized this fact. So what do they do? They make us practice being wrong! We have simulations on reporting a mistake that we may or may not have been responsible for.

In reality, the mea culpa is important but it’s not 

 most important. Our simulation and personal experience taught me that the purpose of humble pie is to remind us that as physicians, none of it is about us. Right or wrong, our patients are the ones that are impacted.

With too much ego in the mix, humble pie can easily go from terrible to intolerable. Humility won’t eliminate this dish, but it can sure help it go down a lot smoother.

This blog has been reposted with permission from 

Are you a neurology resident or fellow? Share your clinical experiences, tips for work-life balance, and career advice on 

Danielle B. Cross, MD, MS, a neurology resident in training, shares her thoughts on the importance of humility in medicine. 

Danielle B. Cross, MD, MS

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