Toxicity in physician training is a topic that is not new. In fact, it’s called residency because traditionally doctors in training spent so much of their time in the hospital that they became “residents” of the hospital. It wasn’t until 2003 that the ACGME adopted a set of duty hour regulations for residents, which were further updated in 2011.
I am a board certified neurosurgeon for more than 11 years, and I completed my residency training at a time when work hour regulations were not regulated. On my first day as a general surgery intern, our chairman sat all the newly appointed interns down and gave an “introduction” talk with a corresponding pamphlet that was titled, “How To Swim With Sharks: A Primer.” This was modeled after the infamous essay written for sponge divers by Voltaire Cousteau in the 1800s. It has been used as a foundation in many fields including medicine, for practical guidance of how to survive toxic leaders.
This pamphlet went on to list several “rules” that must be followed to survive swimming with sharks. The metaphor is that the attending physicians are the sharks, and that the interns are the swimmers. To survive internship, you must learn these cardinal rules. There were six rules stated in this pamphlet that promoted toxicity in health care. In fact, during my internship, this type of behavior that we were taught led one of my fellow interns to attempt to take his own life in the middle of the night in a nursing storage closet.
I would like to re-examine these rules that were given to us, and make them into the rules of today to allow for a more positive learning environment.
1) Assume Unidentified Fish Are Sharks
It is best to assume all unidentified fish are sharks.
MEANING: This presumes that all physicians in the hospital are sharks and can demonstrate aggressive behavior at any given moment.
COUNTER: All training physicians should have the leadership skills to mentor new trainees.
2) Do Not Bleed
When you bleed, you attract sharks. Bleeding will prompt even more aggressive attacks and promote involvement of other uninvolved sharks.
MEANING: This particular rule in medicine is harmful, and acts to ask young physicians to not ask for help when needed. This promotes not only harm to the trainee themselves, but encourages behaviors that can ultimately harm patients.
COUNTER: Showing your weaknesses is a natural part of learning, and learning how to obtain strength in your areas of weakness over time is how you grow as a physician. We are not born with the knowledge and skill set that an attending physician embodies; it is skill set that is mastered by periods of bleeding and healing.
3) Counter Any Aggression Promptly
Be prepared to use whatever force is necessary to repel the aggressive actions of sharks.
MEANING: This forces the learner to always be ready for an attack, and increases anxiety and mental stress which leads to negative thoughts and a heightened sense of insecurity.
COUNTER: Be prepared to overcome your weaknesses with support from your supervising physicians. It is their role to help you grow and learn.
4) Get Out of the Water If Someone Is Bleeding
If another swimmer has been injured and bleeding, get out of the water promptly and do not attempt to rescue the injured swimmer. Your intervention cannot protect him once blood is shed.
MEANING: Do not help your fellow interns out if they are struggling.
COUNTER: We all learn better and feel supported when we have an entire team on our side. We must ALWAYS HELP others in times of need. A robust support system among trainees is necessary for physician wellness.
5) Use Anticipatory Retaliation
Sharks may attack in error, and the skilled swimmer must be ready to retaliate at any given moment.
MEANING: This presumes that the learner must always have their guard up for attack.
COUNTER: Anticipatory support should be expected by all trainees for them to feel supported.
6) Disorganize an Organized Attack
Divert organized attacks by sharks by internally disrupting the attack by having the sharks attack themselves. Consider diverting sharks to the novice swimmer.
MEANING: This promotes behavior of sabotage within the group of sharks with internal dissention. It also promotes the proverbial “throwing another under the bus.”
COUNTER: Teamwork in medicine is extremely important in achieving good outcomes in patient care. Internal sabotage of a team will not be tolerated in a health care environment.
These six rules were laid out like groundwork that day as I sat in my short white coat and white pants, about to enter a new world of health care, in a new city, a new hospital, and with new co-workers. I was scared, and after this talk, I felt empty inside. I saved this pamphlet for all these years in a file folder in my desk, mostly as a reminder of how I felt that first day of July sitting in that hard classroom chair. I vowed that day to not continue these types of toxic behaviors as I grew in medicine. I hope that we can all make those types of promises to ourselves with negative experiences, as it makes us better doctors and better educators. Together, we can change the historic toxicity of health care training, and improve the quality of life of all of those in medicine, including our youngest doctors. Let’s rewrite the pamphlet and ensure that we are committed “lifeguards,” and agents of change.
Dr. Betsy Grunch is a board certified neurosurgeon practicing in Gainesville, Georgia. Her main interests are minimally invasive spine techniques and advancing the field of neurotrauma. Additionally, Dr. Grunch is known online as @ladyspinedoc where she enjoys demystifying the subject of neurosurgery while also showing her audience how she balances work and life as a mother, wife, and friend. Her thriving social media platform seeks to empower the general public with critical medical knowledge, to inspire current and future healthcare professionals, and to add a bit of positivity and humor to your day.
Illustration by Jennifer Bogartz
