ABSTRACT

KEYWORDS

The decade of the 1990s and the first years of the current century was my time as a medical student and resident; first at the Universidad Autónoma de San Luis Potosí and later at the Universidad Nacional Autónoma de México. The medical training of those years would be considered today as completely inappropriate, retrograde and against human rights. In those training programs, what mattered the least was the student's opinion; it was an authoritarian, monotonous, repressive, unidirectional, jealous and, frequently, humiliating training. In spite of these adjectives, that training was very successful because most of the graduates were not only intellectually competent physicians, but also people with a strong sense of identity and a very particular philosophy about life and medical work. A philosophy that we could call "medical mysticism", which at first is the opposite of the earthly or rational. The physician was surrounded by a mysterious halo that made him different from any other professional and that formed and lived, with other physicians, in a fraternity based on respect for professional dignity that was born of having lived through a formative stage with the common denominator of being hostile, adverse, enormously demanding, but that generated a deep shared satisfaction. The institutional and trade union mystique –perhaps tribal– is due to the difficulties overcome during the training period. Physicians of many generations made the mystique their own because of difficult times; not comfortable times. The more effort it took to solve a problem, the more work it cost, the greater the identification and cohesion with the group. Completing medical training was almost like reaching the promised land and that made us heirs to the manna that dignified the physician.

Today we have, amazingly, all of humanity's knowledge at our smartphone's reach.¹ Now machines learn and generate intelligent algorithms, but a few decades ago, knowledge was earned, conquered. Complex searches had to be made in the index medicus and, if lucky, the journal might be available in the library.² Vertical transmission of knowledge from colleagues or residents of higher generations was also gained. We had to show interest, dedication, perseverance, in order to be allowed to explore a patient or perform a medical procedure. It is often said that the current training should not be compared with the previous one because the current world is different from the one that we lived in; I believe that this statement is partially true; however, there are constitutive elements that prevail in spite of generational modifications. The end does not justify the means; that is a truth from then and now, but I believe that the training of the physician, especially the resident, has not been understood. Now there are more and more theories of education and any form of pressure on the student is censured. What has not been understood is that the resident is not trained or educated; the resident is selected. Or, rather, they are made to experience circumstances in which they self-select; circumstances in which the student questions whether they have the talent and fortitude to be a physician or specialist. The training of a physician is like that of a soldier or a firefighter; if they are not taken out of their comfort zone, there is no training. If there is no demand and discipline, there is no training. The physician, the resident, should be trained as far away as possible from their comfortable, controlled area. Do not confuse training with knowledge. The sailor may know perfectly the operation of his ship, the wind direction and the sailing route; but if he has not experienced a storm, it is of no use. No passenger would feel safe with a captain who lacks experience in a storm; what better example of a storm than the COVID-19 pandemic? We didn't know what we were capable of until the pandemic tested us. Now we are better prepared for new storms.

The lives of many people depend on the firefighter, the soldier, the doctor, and on many occasions, their work will have to be carried out in circumstances of crisis, urgency, extreme fatigue, adversity. The resident's training period must be full of obstacles of different kinds, intellectual, ethical, integrative, adaptive obstacles, etc., and only when his determination leads him to overcome them, will they be worthy of being called physicians. It may be an arrogant stance, but the training of the physician or specialist should not be undervalued. We need leading physicians who are strong in action, thought and decision. Physicians who carry out a fast, efficient, correct analysis of consequences, with the least probability of error. An overprotected mind is weak and complains about everything, everything seems negative and victimizes itself. On the contrary, a strong mind accepts, analyzes and resolves. The physician must be, by definition, resilient. This characteristic dignifies our work.

The social image of the physician has deteriorated, there is less and less respect for the physician and we want to be seen as if we were another profession... no, we are not another profession. Whoever sees medicine from the myopic vision of a profession is underestimating the scope of the meaning of being a physician. Medicine is a philosophy of life. The best engine for development is adversity. Adversity generates frustration and the physician must learn to tolerate, manage and sublimate it. A physician with low frustration tolerance should not dissect a pulmonary hilum or perform a pulmonary thromboendarterectomy. A physician who lacks determination and strength in their thinking and decisions should not affect a patient's life.

It is now common that there is no tolerance for frustration and difficult tasks are abandoned; now, more than ever, the law of minimum effort prevails. Now we want success and money immediately, without effort, without understanding that medicine and life are a slow and random process. We want social networks to give us the success we deserve and we want it to be quick. Less restrictive training has been confused with training without limits.

This is the way things are now, the strategy in the training of physicians cannot be the same as that of other professionals for the simple fact that physicians deal with the most valuable thing we have, which is health. Although the work of other professionals is also related to life, the physician's work is special –if not superior– because they try to help the suffering subject. An engineer's mistake, for example, can cost the lives of many people if a building collapses; true, but the engineer works with equations, materials, calculations, projections, all of them "modeled", meditated, even simulated over and over again. Medicine is not like that.

I believe that, if we do not return to the path of discipline and intellectual demand, physicians in training will have progressively fewer limits. The consequence will be intolerance, licentiousness, weak thinking, lack of recognition of authority, absence of leaders, immediacy, victimization. These are characteristics that do not add up in the complex process of restoring individual or collective health. Let us set the limits we need in medical training; I am sure that with discipline, intellectual demand and passion we will make medicine great again.

REFERENCES

1. Short SS, Lin AC, Merianos DJ, Burke RV, Upperman JS. Smartphones, trainees, and mobile education: implications for graduate medical education. J Grad Med Educ. 2014;6(2):199-202. Available in: https://doi.org/10.4300/jgme-d-13-00238.1

2. Douglas A, Capdeville M. From index medicus to the palm of our hands-what's "App-ening" in graduate medical education. J Cardiothorac Vasc Anesth. 2020;34(8):2133-2135. Available in: https://doi.org/10.1053/j.jvca.2020.02.055