An understatement seems the best way to begin—teaching the practice of medicine has been difficult these past couple of years. My colleagues and residents are expressing feelings similar to mine, namely a heaviness and fatigue, “like trudging through snow,” as one resident put it. It all adds up to a vague sense that something just isn't right. Perhaps that something is a potent combination of COVID-19 surges and culture wars, but whatever the cause, it has presented in my life as a desire to put my elbows on the desk, my head in my hands, and disconnect. I am weary of the fight, weary of having to continually come up with new ways to encourage my tired team. I likely haven't been leading well. Although I don't like to admit it, these feelings have probably also affected my ability to be present with my patients and my learners.
I connect at some level with the “tangping” (lying flat)1 phenomenon sweeping through workplaces around the globe, and with the millions who feel that, in all of the upheaval, the one thing they can control is the decision not to work.2 However, on another level I recognize that, whatever convulsions we are experiencing as a civilization, it won't work to collectively take it lying down. Times have been tough before, and tough people have outlasted them. There have been pandemics, as well as social and political unrest before, on arguably grander scales. We are not the first generation ever to feel the angst, ennui, and weltschmerz3 (world pain, world weariness) that are permeating our atmosphere, making it heavy. We are not the first to feel moral injury in the face of seemingly endless suffering, or to question whether lying flat might be easier.
Tangping most assuredly would be easier, but only until the avoided problems have become too large to ignore.4 A generation of physicians opting to lie flat in the face of the great challenges of their time might find themselves judged by history to have abdicated their responsibility to press on, damn the torpedoes.5 And let us make no mistake—“The Great Resignation,” with its anti-work6 and anti-ambition7 components, is threatening the medical profession. New data from the Coping With COVID trial8 demonstrate that 1 in 5 physicians intend to leave their practices in the next 2 years.9 Stop for a moment and imagine the effect that a 20% reduction in the physician workforce would have on our teaching institutions, on our learners and learning environments, and on our society's health.
We must stand up and fight. But we cannot fight in the militaristic sense, pushing through the pain while applying superficial wellness protocols and policies. There are no simple fixes to this problem. The way out for some is to leave academic medicine altogether,10 but this obviously only further depletes the ranks at a time of great need. I would argue that there is yet another option—an individual reconnection to the vocational roots of our profession. Vocation describes a particularly worthy calling that requires great dedication.11 The word invokes nobility, service, and commitment to doing hard things, and doing them from a center of compassion. Reconnecting to this concept might be just the antidote we need to recover from our collective state of weltschmerz.
Throughout recorded history, medicine has consistently been regarded as a sacred calling. Neolithic shamans were depicted as highly valued members of their civilizations due to their willingness to battle the malign forces causing disease, to safeguard life.12 Tracing the history of the profession from Asklepios and his caduceus, to Hippocrates and on into the modern era, physicians have consistently been found answering the cries of the suffering and contagious by choosing a compassionate presence.12 Some have argued that emphasizing the vocational aspects of the profession—versus livelihood—can be turned against physicians, increasing burnout.13,14 Yet far more often, physicians come to realize that no amount of money will make the weariness dissipate.15,16
Just as the pain of the human condition has been ever present, so has our profession had difficulty resisting the weariness that sets in when constantly confronted with it. Anton Chekhov, a 19th century Russian physician and writer, provides an excellent example. In the spring of 1890, Dr Chekhov travelled to a penal colony on Sakhalin Island seeking “a place where he might inoculate himself against the ennui that was slowly destroying his soul.”17 This was not a pleasure cruise as much as a journey into the belly of the beast in search of an antidote. The shocking spectacle of human suffering he experienced on Sakhalin somehow awakened in him a renewed sensitivity, a compassion that he had lost in the day-to-day grind. He later wrote one of his most poignant novelettes based on this experience. Ward No. 6 described the life of a clinician who had once been energetic, even zealous, but had become desensitized by the seeming senselessness of human existence.18 As the weariness crept in, he found himself going through the motions in his work, lying flat. He was finally awakened following a chance encounter with one of his mental ward patients. Paradoxically, the suffering that had numbed him by its constant presence pulled him out of his paralysis. With a Chekhovian flourish, the good doctor's compassion was rekindled by truly suffering with his patients. Reconnection to compassion came not from drawing back or disconnecting from the suffering, but from “leaning in.”19,20
In the same manner, medicine practiced and taught well in this age of weltschmerz must embrace its vocational ancestry.21 There is no realistic path forward if we take it lying down. Perhaps, as Chekhov expressed, we can recover our compassion by choosing to lean in and suffer with those who suffer, despite the difficulty. There is more than an echo of Viktor Frankl's existential therapy, “logotherapy,” in this exhortation.22 And why not? In logotherapy, a will to meaning is paramount, and there is profound meaning in suffering, just as there is in experiencing something or someone, doing a deed or creating a work.23 A time may come when our spirits and bodies will be severely tested, and when a foundation less solid than a belief in the sacredness of our work and the dignity of humanity may crumble. How would our approach to our calling change if we began to see every patient's suffering as inherently meaningful both to us and to them? What if we came to see our own suffering, our leaning in, our compassion, as profoundly meaningful in its own right? Perhaps a will to find meaning in suffering, a Yes to Life: In Spite of Everything, is what we need to recover and impart to our learners.24
I submit that a rapid reconnection to vocation is imperative in our roles as physician educators, lest a generation of young physicians opt to lie flat with disastrous consequences. Can we summon the strength to rise against the weltschmerz? I must believe that we can. After all, pessimism, just as lying flat, never won any battle.25