Fear, Anger, and Pride

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El Greco's Portrait of a Cardinal is known for the somewhat fearsome aspect of the subject's left hand, which resembles a claw as it grasps the edge of a chair. There has been some argument as to the significance of this gesture, but as I looked down at my own hand gripping the edge of my own chair, I knew without a doubt the reason I was doing it: I was angry.

A senior physician had just told a room full of faculty and house staff that he was afraid. We had been gathered to discuss changes in the Internal Medicine residency, and I was one of the youngest faculty members at the meeting. The man looked around the audience and commented on the large number of residents present. He noted that these residents would normally be back at the hospital, doing the work necessary for the care of the patients. In fact, he said, the hospital could not function without them. This observation made him afraid. Much better, he stated, would be a system that would function without a single member of the house staff showing up for work. That way, the house staff could focus on their real job: learning.

Why was I angry with this man? It is true that he had contradicted much of what I believe about medical education, but that alone would not have made me so angry. He had also violated my sense of pride—the pride of a person who had been a medicine resident and then a renal fellow not so long ago.

It was a pride born of fear. Seven years before this event, I had been walking down a corridor in a different hospital, and I was very much afraid. It was a Sunday, and rounds were over. My attending, one of the true master clinicians in the department, had just left the hospital. As the intern, I was now responsible for our patients until the morning when my attending would return. When he was present I could never be afraid—after all, he knew all the answers and made no mistakes. But now the medical ward, which had been so loud and chaotic during the week, had become eerily quiet. Although I knew there were many places I could turn to for help, that fact did not take away my fear. After all, there were still so many decisions lying in wait for me, and each was an opportunity for failure. What if I dismissed an important symptom, or ordered a medication incorrectly? What if I failed to phone a superior when I should? In short, what if I was bad at my job? Although many questions passed through my mind, I never wondered: “Am I responsible for these people?” It would have been an absurd thought. Of course, I was responsible—that's why I was afraid.

Two years later, walking down the same hallway, I passed a colleague walking in the opposite direction. A few seconds later, I passed another, and then a third. Each time I passed one of them, I felt a surge of pride. We had worked together during all this time, and we had all been afraid. But I felt quite confident that each of us made good decisions; we certainly had made a lot of them. Of course, these decisions were always later reviewed by someone more senior, but, for a few hours at least, these decisions were our own. And, as the months went by, it took scenarios of greater complexity and uncertainty to inspire our fear. We had spent a large amount of time taking care of patients, and we saw that as our job. As I walked past my friends, it occurred to me that they were quite good at that job. I felt proud to be one of them.

Now here I was, five years later, being told that we should never have had those jobs in the first place. This first made me angry, then afraid. What would happen, I wondered, if this man's vision were to come true? Since I am now a faculty member in Nephrology, most of my decisions are made without anyone looking over my shoulder. There are many times when I am still afraid, but I can draw on the experience of the countless decisions I made while under the vigilant eyes of others. And because I felt responsible for those decisions, a sense of identity formed. I learned to see myself as an integral part of patient care—a part without which the hospital could not successfully function, anymore than it could get by without nurses, or accountants, or, yes, even attendings. This role forged a sense of ownership over my work, and I still rely on that sense today. After all, should I recommend a kidney biopsy to the young pregnant woman with features of both lupus nephritis and preeclampsia? Should I let Mr Smith try home hemodialysis again, even though he just spent 2 months in the hospital? Should I immediately place a dialysis catheter in that coagulopathic patient with an elevated potassium level, or should I wait until morning? Since I am the attending, the responsibility for doing something or doing nothing is now truly mine. But if the responsibility had arrived all of a sudden, instead of gradually over many years, then that would make me truly afraid.

Looking at my hand for a second time, I thought of El Greco's painting anew. I remembered that the man in the portrait was not a nice man. Without going into historical details, he was a figure in whom fear, anger, and pride all combined into a dangerous self-righteousness. Now here I was, imitating his pose because I was angry at someone for questioning a system I believe in. The parallel gave me pause. Could I be attached to a system of training simply because it was the system that had produced me? Could I be romanticizing my experience while ignoring important limitations and risks? Was I angry at the man at the podium less because of the danger he represented to the future, but more because of an insult he had offered to my past?

Much as I tried to question my motives, I could not shake the conviction that I was right. The residents in the room with me were junior professionals, who should be expected to carry out their jobs well. Performing those jobs was the best way to prepare them for the future, when they would eventually replace the gray-haired man at the podium. In spite of being so obviously correct, I did my best to let go of the chair.

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• Credit: The Metropolitan Museum of Art/Art Resource, NY.