I am currently writing an opinion piece on the medical
skills necessary for current and future psychiatrists. I designed a table and sent it to my favorite
internist for feedback – my brother. He
was concerned about my level of intensity and wrote back:
“In an ideal world this sounds good. In my experience most
psychiatrists do not have your zest for medical knowledge. Enthusiasm is hard
to teach.”
His response got me thinking about the enthusiasm factor in
academics and medicine. Is it teachable
or can it be transmitted some other way?
What about the issue of authenticity?
Is the observable really enthusiasm or is it something else appearing to
be enthusiasm? Competitiveness is
probably a good example and it is legendary in pre-med and medical school
courses. There appear to be plenty of
people who adhere to the old adage about escaping a bear attack: “I don’t have
to be faster than the bear – I only have to be faster than you.” When I was in med school these people were
known as gunners because on rounds with attendings they were gunning for
you. They would attempt to elevate their
status by trying to make you look bad. In some cases that took on the
appearance of just trying to look more interested than you. I never really understood the mentality
because after all we were in the presence of an attending who could make all of
us look bad – and typically did.
My interaction with professors and attendings was the first
real sign that true enthusiasm exists.
In college at every level there were professors with vast knowledge of
their subject material. At times they
would interject their personal excitement about the subject matter into the
lectures. Anecdotes about the organic
chemist who famously said that God consults him about molecules, the
inscription on Boltzmann’s grave, or the mathematician who died in a duel at
age 20 and the implications. Some of these professors would read the room and
try to inject humor to invigorate the class and create some enthusiasm. And
there were the obvious sacrifices like hanging in there as a professor or
adjunct at a liberal arts college for substandard pay and benefits for the love
of the academic field and the ability to practice it.
In medical school, it was even more obvious. Most of the people med students interact with
are attending physicians on clinical rotations who teach but also have their
own productivity demands. Physicians
rounding on patients with a teaching team have their clinics or surgeries in
addition to supervising trainees. They need an academic level of expertise in
their field to maintain the teacher-student hierarchy. A pediatric endocrinologist told me: “I must
know the most about any endocrine subject in the room (referring to the mix of
specialties on our ward team). It is no
accident that I know all about adrenal steroidogenesis. I have to know it cold.”
Was that still about competitiveness and one-upmanship? Possibly but highly unlikely. After all an attending physician is not
competing against trainees or anyone else.
If there is any competitiveness it comes down to internal
standards. As an attending for me that
came down to a series of questions:
1. Am I missing
anything?
2. Am I doing an
adequate job?
3. Am I covering
everything that is important to cover and am I communicating what that is?
4. Are there any
problems with the staff or trainees that need to be addressed?
Competitiveness does persist post training and it is a
largely undiscussed problem. I once witnessed
a confrontation between two very high-level academics where one commented that
he would never be beaten by the other.
The rejoinder was: “I think the field is big enough for both of us”. In the
current American system, it is encouraged among front line physicians using several
metrics like productivity (number of patients seen not papers read) and various scapegoating techniques in the corporate
employee assessment. But I think most senior physicians get to the point where
they welcome collegial discussion and consultation. If you discussed it with them – their
competition is most likely against high internal standards – some of which may
be unrealistically high.
The psychology of enthusiasm has several dimensions. There
are behavioral approaches to improve it – not the least of which is establishing
predictable routines. Athletes routinely
push past nonspecific feelings of unwellness and notice that those feelings resolve
and they feel much better with their workout routine. This helps establish a long-term pattern of
enthusiasm for high levels of exercise.
There is a social component that is used in sports for both the athletes
and spectators involved. Like all
psychological phenomena there are rating scales that seek to describe the enthusiasm
of teachers
and work engagement in general (1). In
the age of burnout several studies have suggested that enthusiasm may minimize
that problem. It would be difficult to
maintain enthusiasm in the face of moral injury.
From a psychodynamic perspective, identification with teachers, professors, and attendings is a largely unspoken but in my experience powerful process. In clinical medicine there is probably no better field to observe personal attributes of teachers and consciously or unconsciously incorporate them into your personality. I was fortunate enough to work with so many enthusiastic and high energy physicians and teams and they had a direct impact on me. The message was be compulsive, check and recheck everything, and do the research on the fly. I have written about the last team I worked on in medical school. Every person on that team from the intern to the 70-year-old nephrologist was interested in kidney disease 24/7 and we covered the largest inpatient unit I have ever seen (including transplant patients) and two outpatient clinics. We worked at it from sun up to sun down and everybody was energetic and ready to work. That team also showed me the importance of a sense of humor. Everybody had it but one of the Internal medicine residents was practically a stand-up comedian. On my last day of medical school, I worked until 10 PM with that team. They were swamped with consults and asked me to do three after the clinic. I was happy to do it and then skipped across the golf course like county grounds to my apartment a half mile away. Even as an old man – I feel happy every time I think about that experience.
As I am winding down this post, there is a moral dimension
to enthusiasm at least as far as medicine goes.
People have been described as doing harmful things enthusiastically. Enthusiasm has to be a positive force. One of the derivations from the Greek is “possessed by God or divinely
inspired”. At times in history, it has
been equated with madness. Philosophers
have written about it as both a positive (promoting desirable values and
politics) and a negative (zeal overtaking rationality). In the context I am discussing – it takes the
form of improved focus on difficult to solve patient problems and espirit de
corps.
Identification only gets you so far – I don’t think anybody
has ever mistaken me for a comedian.
What about in the case I started this post with? It was my brother responding to a compulsive
table about what medical problems psychiatrists should be able to recognize,
diagnose, and either treat or tirage. Enthusiasm may be a part of that and I
will admit to being very enthusiastic about medicine and neurology in general,
but there is more going on. I made most
of the diagnoses in the table not just based on enthusiasm but at least three
other factors. First, I practiced across
multiple settings and was often the only psychiatrist around. When you are asked to see people in general
hospitals, nursing homes, and outpatient clinics in the same week there is a
good chance that you will encounter serious but vaguely characterized problems
in all these settings. That could range
from agitation due to any number of underlying neurological conditions to a
mother who wants her 3-year-old son put on stimulants because of uncontrollable
behavior. Second, neurologists are in
shorter supply than psychiatrists. That
doesn’t mean that psychiatrists should practice neurology but it does mean that
specialists who are trained in and expected to know neurology might do a better
job with certain problems than primary care physicians. At the top of that list
are recognizing aphasia syndromes, presentations of acute encephalitis and
meningitis, movement disorders, and functional neurological disorders. Third, there is always a group of psychiatric
patients who see their psychiatrist as the primary care physician they prefer
to follow up with. I have been able to
diagnose unrecognized illnesses just based on that difference in preference and
communication. Psychiatric liaison with
primary care is a useful function.
Heading into 2026, I hope that all the professionals reading
this have been exposed to the levels of enthusiasm that I have during their
career. And I hope that the
doctors I end up seeing in the future all have it.
George Dawson, MD, DFAPA
The residents were trying to cajole me into doing the work but they did not need to. When I said I would they increased the flattery to absurd levels and we all had a good laugh about it.
References:
1: Schaufeli WB, Bakker AB. Utrecht work engagement scale: Preliminary manual. Occupational Health Psychology Unit, Utrecht University, Utrecht. 2003 Nov;26(1):64-100.
Graphic Credit:
Teaching hospitals of the Medical College of Wisconsin taken
from the path walking from my apartment on 89th street. The black and white photo is Milwaukee County
Hospital shot in 1982. The color photo
is from the same spot in December 2025.
The two most visible buildings are the Froedert and MCW Center for
Advanced Care (left) and the Froedert & MCW Clinical Cancer Center. The Froedert legacy spread from the original
Froedert Hospital that was there is 1982 - where I did 2 neurosurgery, a
nephrology, and a neurology rotation.
B&W is shot with a Konica 35 mm and Ektachrome. Color is an iPhone 15.
No comments:
Post a Comment