I was reading Reaching Down the Rabbit Hole by Dr. Allan Ropper, and came across a passage near the end of his book where he is talking about his experiences during his training; what it was like training with the "old guard", their spirit, and contrasting that with his current job of training future physicians. Here is a short bit,
"Raymond Adams, C. Miller Fisher, and even Doc Vandermeer belong to a generation of physicians who were so wrapped up in the ethos of what they were doing that they inadvertently gave rise to the cults of personality that warped the sensibilities of their acolytes. The ethos served a social good, so the cults survived for a time, but have now made way for a collective caring for patients which has supplanted personality. Part of my role today is regrettably to lead the next generation of neurologists from the old school to a new one, to turn them into interchangeable parts in a new health-care system. Yet I want them all to be best in show."
He goes on to tell about the negatives of the old guard way, like paternalism, ludicrous levels of personal sacrifice, and "elitism tucked behind a mask of benevolence". But ultimately, despite the flaws, he states that their way led to countless lives saved.
What do you feel about this passage? Do you agree that the newest generation is being trained to be interchangeable? I am just an M1, but I see online and frequently hear in person older physicians denigrate the ethos and ethic of their younger colleagues (not that this is what Dr. Ropper is doing). Are these just more examples of juvenoia, or should we in training do differently - and if so, what? Thank you for your thoughts!
In inpatient IM, they are being trained to be cogs, 100%. They are not allowed to have an original thought, just consult, order tests, and be nice (except also get them out ASAP). But neurology can never be interchangeable. There are differences in styles depending where you go, whom you emulate, and intrinsic differences. I modeled myself, consciously and unconsciously, after the attendings and senior residents I found competent and who's style resonated with me. And those who didn't, I tried to be the reverse.
I met Ropper on the interview circuit, and he's not my cup of tea. He fostered exactly a cult of personality that I found weird. I find it even weirder that he calls these three out for doing what was so obvious in him! And he's exactly wrong. Cults imprint the students with the ONE TRUE WAY, so that you can go on and become a Ropper trained person (3-4 years) for the next 40 years of a career. Seems to me that he's created his fair share of cogs. He was one of many.
Also, I'm sorry, but that book wasn't to my liking. Someone gave it to me BTW. Cutting down his chief resident because she dresses weirdly (but it is modern medicine that will make her a cog) and bikes to work? I think I made it to the second effortless autoimmune encephalitis diagnosis before giving up. Perhaps it was the first. But good for you for sticking to the end.
Its pretty accurate i think.
I don't think any of this is a deliberate attempt or scheme by an older generation. Also if this is happening naturally, doesn't mean it is bad.
Its just that Health care has changed dramatically. There is significantly increased medicolegal liability, accountability and higher expectations from our generation. Also medicine has become way more algorithmic and technology driven.
We also have to be way more empathetic (or at least act to be). I remember having a meeting with administration talking about how to make patients "happy". They want medicine to be a hospitality business and doctors to act like that. You will hear this a lot in your training now-days. Older generation could have a personality; newer generation is allowed less room for different personas. We are indeed becoming interchangeable.
Yes, but only in big hospital systems. Get a job in practice. Be yourself. Abandon Press Ganey nonsense. I would have walked out of that admin meeting. You know what makes patients happy? Lack of candor, opioids, Ritalin, Benzos, quackery, never report seizure patients/stroke/AD to the DMV, and unnecessary testing. Yes, be pleasant, but abide by real medicine. Dr. Oz is plenty popular. He's also a repulsive charlatan.
Oh, Allan. Such flair for the dramatic.
RDA and CMF were products of their times, hothouse flowers that could only exist where they were planted. They also didn't speak to each other for like a decade, despite their stature as giants in the same department. Over countless retellings, their positive qualities are exaggerated and their weaknesses are minimized. Great physicians and useful to learn from in some aspects, but emulating their care delivery would not yield better outcomes in the current medical world. Fisher would sit in the White 12 nurses station at 3AM counting startle-myoclonus episodes of a patient he thought had prion disease. Is that simply a monastic devotion to the science and practice of neurology? Masochistic self-satisfaction? An awareness that these sorts of behaviors attracted attention and adulation that only added to his legend? Simply something to do because services were not nearly as busy and there were essentially no treatments for the vast majority of his patients? All of the above? Curiosity and drive are excellent attributes, but in my experience they only expand to fill the size and shape of the container they are placed in. I would argue that some of us are more interchangeable than others, but overall the demands placed on us by our environment limit the opportunities for the extreme attitudes and ethos/pathos that led to these guys becoming famous and field-defining in the first place. Things change, time marches on. Stroke outcomes are demonstrably better and therapeutics substantially more varied than in Fisher's time. That's not his fault, but it's so apples-to-oranges that comparisons are strained, and those still in a position to have directly observed both situations often have a vested interest due to nostalgia.
Wow, didn't know all that. Sounds like undiagnosed Asperger's or OCD.
All these guys are walking examples Feynman (another troubled genius) warned against. I might be getting the person wrong, but I was once in an audience in which Caplan told us that tPA will not work in lacunar strokes full stop. Well, the field looked at lacunes and tPA works. Did Caplan or anyone at his site do the NINDS study?
Medical science is constantly evolving, constantly getting better - or should be. What these guys did was a amazing, but Ropper is right to call them out. Like Galen, they initially advanced the field by light years, and we should remember them for that, but then they created dogmatisms and intransigence to novel approaches. Part of the intransigence was due to the fact novel therapies didn't come from their research and that the RCT is intellectually easy. You don't get to be philosophical or whimsical, the patient meets criteria or not. And it limits the ability to pontificate on one's pet theories.
