At the core of every doctor's training is the internship, that first year of residency that begins just a few weeks after all the pomp and circumstance and lighthearted celebration of medical school graduation. Sometimes referred to as simply the first year of residency, internship is the first step in a professional journey that could include several more years of residency training, a year or two of subspecialty fellowship, and another year or two of research before one ever reaches the goal of becoming a fully trained doctor, an attending physician.
I began my internship as part of a class of five, two women and three men who had all done reasonably well in medical school. By the end of our second year, however, three had left. None of us had ever expected such an attrition rate; our teachers, the attending surgeons, had not intended, as some residency programs did at the time, to fire two of my peers. None guessed that a third would simply up and quit.
The two of us left standing knew that the official reasons were poor judgment and "unprofessional behavior" — we had heard that one of our classmates had repeatedly violated patient confidentiality, and the other had made a decision that put a young child's life in danger. But after their departure, the two of us remaining became fast friends.
We had to be, given the stark facts: we were working well over 100 hours a week with the possibility — the sheer fear, really — that we could be next in line to be fired and would lose all we had worked for until that point. Our dismissed classmates had struggled to find work after leaving; one had begun training all over again in a different specialty, and the other eventually left medicine altogether. Without the support of the other remaining intern, my best friend, I could not have survived.
We did make it through residency, and we learned during our internship and our second year to stay as far away from trouble as we could. "Remember," the two of us often warned one another, "you're only one slip-up away from one of those guys."
Negative reinforcement during those early years taught me to be a cautious and conscientious doctor. Our teachers rarely praised us for good work and never allowed us to forget our errors. But sometimes the lessons had little to do with learning how to care for patients.
One night during my internship, for example, a powerful senior attending called to chew me out for putting his V.I.P. patient in a double room. His voice was so loud I can still remember holding the phone away from my ear. "Do you know I can get you fired for this?" he roared.
"Yes, sir," I responded meekly. I was too scared to tell him the truth, which was that the head nurse, not the intern, assigned patient rooms.
Those early lessons were so effective that even today whenever I hear anyone say the words, "I need to talk to you," my first response is: Did I do something wrong?
I believe strongly that we need to train young doctors to be competent, caring and conscientious. And I would also say that most individuals in my profession feel the same way, judging by the degree of interest in journals and professional societies in cultivating "professionalism," the buzzword used to encompass all those desired qualities. "Placing the interests of patients above those of the physician, setting and maintaining expert standards of competence and integrity, and providing expert advice to society on matters of health" is how one international gathering of medical groups summed up the goals of "professionalism."
I just wonder, though, if emphasizing the negatives — what not to do and the terrible personal repercussions — is necessarily the best way to go about teaching professionalism.
Recently while reading The Journal of the American Medical Association, I came across a study on professionalism that addresses positive reinforcement. Using observation-based evaluations, Dr. Darcy A. Reed and her colleagues at the Mayo Clinic in Rochester, Minn., assessed aspects of professionalism like compassion, competence and integrity among 148 residents and then examined the specific behaviors of the most outstanding among them.
I read through Dr. Reed's paper once and had difficulty understanding her premise; there was little mention of the negative behaviors young doctors needed to avoid. I read through the paper again and this time noticed that even the so-called "average" residents in her study behaved in a very "professional" way. The differences in professionalism between the outstanding residents and those who were average were not that disparate.
In other words, most residents were trying their best to be good doctors.
I called Dr. Reed.
"People have a natural desire to do good, physicians especially," she said. "But the problem," she continued, "may be a training system that encourages not how I can improve but how I can survive."
Doctors-in-training, Dr. Reed maintained, want to know how to improve. But many of their teachers, individuals like myself who were exposed early on in their training to negative reinforcement, might not necessarily understand how encouraging rather than ignoring or discouraging might work in residency. Moreover, even for those educators who are comfortable with positive reinforcement, it is still not entirely clear which behaviors correlate best with professionalism and are thus most important to encourage.
Which is the reason why Dr. Reed and her colleagues chose to focus on only the most highly-rated residents in their study. "What is it about outstanding residents? And how can we all emulate and encourage that behavior?" she asked me on the phone. "We want to encourage residents and the behaviors that we know are associated with outstanding professionalism."
Dr. Reed paused and then added, "Negative reinforcement is so defeating. There are far fewer people who need negative reinforcement than those who need the positive."
I got off the phone that morning feeling a little unbalanced, as if I had been handed a new pair of glasses to wear. Maybe I did not need all that early negative reinforcement to have become a conscientious doctor. Maybe all those fears my best friend and I shouldered during our internship and second year of training were unnecessary.
I read Dr. Reed's paper yet again and suddenly remembered her answer to a question I include in all my interviews: What was it personally that got you interested in this topic?
Dr. Reed had, I noticed, answered without a moment's hesitation. "I became interested in educational research through interest in teaching. I was impressed by excellent teachers and wanted to emulate them."
She had learned, I now understood, through positive reinforcement.
