From the trenches: More about grit

The following was compiled from two comments on my recent post about grit written by a doctor who calls himself "Geronimo." It is reproduced with permission.

Grit cannot be assessed by a survey. I wholly agree. As a military physician, my firmly founded opinion is that grit is essential to the practice of medicine. Grit is the elusive characteristic that carries the clinician through the challenges that exceed ordinary capabilities. You cite a paper that argues for surgical training to borrow aspects of SEAL training. I applaud any measure that would allow senior faculty and program directors to unilaterally shape their residents’ training, whether or not it bears any resemblance to the rigors of BUD/S [Basic Underwater Demolition/SEAL training].

The 2011 loss of 30-hour call for medical students and interns was a fatal blow to residency training, in my estimation. I count myself fortunate for having a 30 hour call internship before embarking on my operational career. While downrange, it is not at all uncommon to be woken at inconvenient hours of the night to tend to the wounds of war. If you don’t know how you function cognitively, physically, psychologically, and emotionally while sleep deprived, exhausted, hungry, cold, and pissed off, you’re behind the curve. While it isn’t any fun to work in such a state, or to work with people so challenged, it is decidedly less fun to be a patient expiring for want of any medical provider, let alone a tired one. American medicine used to be in such a place in the not so recent past, to hear the story told by my forbearers.

How often does disaster visit that requires sleep be sacrificed? The headlines recount a few – Katrina, Boston Marathon, Tropical Storm Alison, 9/11. No doubt there were physicians stretched beyond their ordinary limits for each of those ordeals. How often does it occur that a physician or surgeon must work beyond their ordinary limits for a patient whose ill begot fate failed to generate the attention of the press? I’d be willing to bet it’s on a monthly basis at least.

You sir, are a senior practitioner, and physicians like you taught me the practice. You know better than I why long hours and challenging training are essential, sir. My only question, sir, is why residency training standards were diluted and degraded at the behest of nurses, OSHA, and likely other “powers that be”, when you knew it was the wrong way. Why don’t modern program directors, department chiefs, make a stand? If there exists widespread agreement that the current methods don’t meet the standard, why pretend that they do? If you are a retired PD, you have a privileged position as not having to fear retribution. Use your bully pulpit to build consensus, unify the opposition and mount the attack.

Your SEAL post had a comment from a Man’s Greatest Hospital surgery program director who lamented the demise of training standards in the same fashion. I find it demoralizing that PD’s have been rendered impotent in the face of these trends. Obviously this will require a near unanimous front of PD’s and department chiefs. If your generation matriculates from practice without this trend being reversed, I believe it will be too great a task for my generation to overcome.

And for what it's worth, I enjoyed the comments of TheTracker…

The utter incompetence of your generation—killing tens of thousands of patients every year with preventable errors secondary to the irrational systems, sloppily maintained, that you and your colleagues built up and managed.

Not to be blunt, but maybe while we're struggling to clean up your mess and catch up with the rest of the developed world, you could forgo your attempts to shift blame with anecdotes?

This is pure unadulterated nonsense. I really can’t figure out what he’s talking about, but would venture the guess that he is a fan of checklists, timeouts, shifts that don’t exceed 12 hours and bubble baths. I don’t live in his world, and don’t want to. I am a doctor.

All doctors faced an attrition rate that exceeded BUD/S trainees matriculation to operational SEALs. Among aspiring physicians, 80-90% or more, are weeded out through undergrad prereq’s, MCAT, and the like. It should be an arduous, stressful endeavor to become a physician, just the same as it should to become a SEAL. Lives depend on SEALs’ and physicians’ capacity to demonstrate grit. Bearing that in mind, we should demand the same high standards and control over how we bestow the privilege of practice on the next generation. As it has been said many times, it is harder to stay in Ranger Battalion/Special Forces Group/SEAL Teams than to become a Ranger/SF Soldier/SEAL. The same is doubtless true of surgery and medicine. Medical and surgical training programs should reflect that reality.

Is Geronimo right or wrong?