August 25th, 2015

Motivations of a Doctor in Training

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

As my co-chiefs and I try to figure out how to best serve our residents and deliver a worthwhile education to them, I have begun contemplating what it is that really motivates doctors in training. What is the driving force behind a resident striving to be a more knowledgeable clinician? How do we convince them that they need to work hard and take an immense amount of time and exert an enormous amount of effort to acquire both the didactic knowledge and the clinical sense required and expected of them by their profession and patients?

After a lot of thought and discussion with colleagues, I have found that the drive for each resident is a unique combination of 4 major factors; every resident’s makeup varying the exact ‘amount’ of ingredient that needs to be tapped into to make their training experience worthwhile and productive:

  • Fear/Guilt… That knot in the pit of your stomach… that globus sensation that makes it impossible to swallow… that nightmare that wakes you up in the middle of the night as you replay all of the things you missed earlier in the day. It is the fear of killing someone — a drive that is so potent that it leaves residents googling the side effects of the Benadryl they just prescribed as they sit on the toilet between bouts of irritable bowel syndrome at 2AM. This fear and guilt is healthy, but, if not tempered at the beginning of residency, it can be all consuming and harmful. It is a powerful motivating factor when you recognize the immense responsibility that you have — that your order might permanently change the lives of another human being and his or her family.
  • Signs that your resident is highly motivated by fear/guilt:
    • Twitchy and nervous on rounds
    • Frequent bathroom breaks
    • Checking and then rechecking orders and notes the way Jack Nicholson checks his door locks in “As Good as It Gets.

Jack Ncholson

  • Shame… Do you remember when the teacher called on you and asked you a question that you definitely should have known the answer to, and you froze? Can you recall how you felt the warmth of embarrassment crawl up your chest, pass your palpitating heart, move through your almost completely closed throat and into your now red cheeks? Do you recall the deafening silence that you were responsible for weighing down on all your peers, and the 9-month-pregnant pause your teacher allowed to mature into a full-grown baby of shame and self-loathing? Do you remember thinking about that time over and over again and re-living the terror of that moment of humiliation? That is the moment of shame that drives some of your residents to read, to work harder, and to always be prepared.
  • Signs that your resident is highly motivated by shame:
    • Crumpled up notes in overstuffed white coat pockets
    • Coming to the hospital 2 hours before the next resident for pre-pre-pre-rounds with multiple cups of coffee on board before the team attending has even rolled out of bed.
    • Overly concerned about evaluations that peers and attendings spend about 4.7 seconds of mindshare completing.

hiding cat

  • Ego… or the Id, if you want to get all Freudian on me. It is the impulse to want to be the best and to triumph over all others. This is the drive that makes you seek the admiration of all, the respect of those beneath you, and the recognition of those ethereal beings we know as attendings and administration. It is the desire to attain a status in which you can look in the mirror and say you did it and declare to everyone, or sometimes nobody but yourself, that you are the epitome of what a doctor should be. I also take the liberty of placing attainment of loftier position/money in this category of motivation — i.e., fellowship and dollar bills.
  • Signs your resident is highly motivated by ego:
    • Aspiring cardio fellow (likely a ‘gunner’ intern) that walks around with calipers in his pocket despite being on an outpatient rheumatology elective.
    • Pristine white coat over an Armani suit, far too much hair gel or the clickiest shoes in town.
    • The resident who takes every opportunity to quote obscure papers from Scandinavian research cohorts written in the 1950’s that almost never pertain to the patient or patient population at hand. Impressive? Yes. Clinically applicable? Never!

Ego

  • Vocational Aspiration… Close your eyes and think about the physician you always wanted to be like. The one who gets down to eye level with his/her patient, speaks confidently about the matter at hand, shows love and compassion that cannot be faked or learned in a textbook, and exemplifies the characteristics of a healer. You see this in the resident who has taken medicine on as a vocation… as a calling. It is who they are and as a consequence, they take it as their responsibility and duty to strive for well-rounded excellence because, to them, there is no other option. This is the drive we strive for but only catch glimpses of when we are not devoured by our fears and shames and egos. If you ask every resident why they do what they do, they give answers that fall into this category: “I want to help people.” “I want to make people better.” “I want to make myself a better person and doctor.” It is what we write in residency application essays but seldom see in ourselves while in training. This is the most important motivator to trigger and mature in the residents we work with. All of the others are important tools to get people going, but without this, we are producers of machines and not physicians.

 

Factors/Motivators that deserve an honorable mention:

  • Golden Child Syndrome
    • “My parents made me do it.” You know these people. They were told what to do and are good at being told what to do.
  • The Challenge
    • The intellectual challenge of medicine drives so many physicians. The puzzle that a clinical case represents can be enough of a driver for some residents.
  • Silencing the Naysayers
    • There are some who do what they do because they have been told they cannot do it. Medicine…then Mt. Everest. See Ego for further detail.
  • The Narcissist
    • “Let me take a selfie while I sew up this laceration like a plastic surgeon.” Are you noticing an ego trend?

There are probably tons of other motivators you see that get people going. Share them in the comments and tell us the tell-tale signs that come with someone who is motivated by that factor.

~Yousaf

9 Responses to “Motivations of a Doctor in Training”

  1. Cathie M Currie, PhD says:

    All of the cited ‘motives’ have a negative slant!

    Humans have a core motivation, but it is generally ignored in education including medical education. Prime the pump, and get out of their way. Here is an example in pre-medical education:

    I had a new research assistant who had been re-located into a new office just before my vacation. A week later, I came back through NYC to repack for the beach. My PI called to say: “Your RA has done NOTHING since you left. A manual she needs got lost in the move, and she can’t find it. Cancel your vacation, get in here!” My RA was in a gap year, reapplying to medical schools.

    I repacked my bags, and I stopped by the hospital the next morning to set the RA back on track. When she arrived, the first thing she saw was the ‘lost’ manual which I had placed on the seat of her chair. Then she saw me. She tried to fawn: “I knew YOU could find the manual!!” I only said: “It seems to me the requirements for visual acuity are much higher for a MD than a PhD.”

    She paled. Then changed gears: “You are SO RIGHT! I have to catch up!! It will ALL be done THIS WEEK!! Go back to your vacation. Whatever was going on with me, it’s OVER!! Geez, what WAS I thinking!”

    I didn’t say another word, I just left. On my way out, the PI spied me and demanded I stay. “It’s fixed.” I said, and I breezed past her. The RA was superb from that point on. She is now an excellent MD.

    Core motivation. All you have to do is acknowledge it. Even some really damaged people will cling their last remaining threads and do the right thing. The key is figuring out exactly what motivates them. It is NOT shame or fear. Core motivation is always a positive.

    • Tanna Lim says:

      I agree everyone is motivated by something (i.e., core motivation) and as a former chief, part of my goal was to figure out what exactly that thing was. Fear absolutely can be a motivating factor–maybe not the best motivator but one nonetheless. Certainly positive motivating factors are preferred but the negative ones should not be discounted.

      • Cathie M Currie, PhD says:

        I saw a lot of fear induction during my postdoc and work in medical education. Never once did I see it have a positive result.

        Urgency has a positive result. Urgency is VERY different from fear. I hope you mean urgency.

        • Ahmad Yousaf, MD says:

          @Dr. Currie: Urgency may be a better word to describe this motivational factor. Thanks for the comment.

      • Ahmad Yousaf, MD says:

        @Dr. Lim: 100% agree! The goal should be to tap into all of the factor that get people going with the aspirational factors teased out and enhanced! Thanks for the comment.

    • Ahmad Yousaf, MD says:

      @Dr. Currie: That story is a great example of tapping into that aspirational motivational factor. I appreciate the advice and comment!

  2. Tokir says:

    Useless article without any practical implications. As a chief I expected the writer to
    provide some improvement and enhancing tips. Rather than categorizing his residents into certain stereotypes the writer is better off sticking with the principle described by himself at the beginning.
    “As my co-chiefs and I try to figure out how to best serve our residents and deliver a worthwhile education to them.”

  3. David Chakoian says:

    I am saddened by the negativity and apparent cynicism in Dr. Yousaf’s essay. I am in a community practice in the Midwest, so my environment is significantly different.

    The trainees that I see (granted, limited in number) generally show a sincere interest in learning, a curiosity, a sense of responsibility and sometimes still a sense of wonder. What I see is a commitment to service. Yes, this varies among individuals, and the negatives remain part of the picture. But I see primarily positive motivation.

    It may be that, in Dr. Yousaf’s institution and many others, the curiosity, wonder, responsibility, and desire for service have been beaten out of the trainees – or that the programs don’t select residents with these attributes. Either way, Dr. Yousaf does a disservice to his residents by losing sight of these higher motives. There really is an alternative to the House of God way.

    • Ahmad Yousaf, MD says:

      Your point is well taken. I agree that there is definitely an important role in uncovering the positive factors that motivate us as physicians (and I consciously left many off of the list). Personally, I experienced all of the ‘negative’ factors discussed in the article as I trekked through residency and found that they all played a part in me moving forward and becoming a better doctor. The goal, however, should definitely be that “vocational” type of motivation playing the largest part in what drives us. Thank you for the comment.

Resident Bloggers

2019-2020 Chief Resident Panel

Prarthna Bhardwaj, MD, MBBS
Eric Bressman, MD
Allison Latimore, MD
Daniel Orlovich, MD, PharmD
Frances Ue, MD, MPH

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.