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Otolaryngologist Kevin C. McMains discusses his article “The hero’s journey: Understanding professional identity formation in graduate medical education.” Kevin discusses the ongoing crisis of burnout and mental health issues in medical training, critically examining traditional educational and environmental interventions. He identifies a gap in the current narrative surrounding work-life balance, suggesting that framing work and life as dichotomous can inadvertently diminish the intrinsic rewards of caring for others. Kevin proposes an alternative, more emotionally powerful narrative for professional identity formation: the hero’s journey. He explains how this framework, rooted in universal storytelling traditions, can help medical trainees find deeper meaning in their sacrifices and engage more profoundly with their patients, fostering a more resilient and compassionate generation of health care professionals.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Kevin C. McMains. He’s an otolaryngologist. Today’s KevinMD article is “The hero’s journey: Understanding professional identity formation in graduate medical education.” Chris, welcome to the show.

Kevin C. McMains: Hey, thanks so much. I appreciate the opportunity.

Kevin Pho: All right, so just give us a brief story and journey, and then tell us why you wrote this KevinMD article.

Kevin C. McMains: Sure. I’m of a vintage that trained in what is now sort of dismissively referred to as the bad old days. In fairness, there were a lot of elements of that that were unnecessarily harsh. What I’ve observed over time is that trainees of mine have elected to resist some elements of training that are actually really important for them: developing skills, developing knowledge, developing attitudinal expertise that are going to be really valuable, maybe even necessary to them as practicing clinicians.

The way that I’ve interpreted that is that it seems that this notion of work-life balance has supplanted whatever else used to live there at the apex of the value hierarchy. In general, I’ll go on record to say I’m for it. I’m for work-life balance. But I also asked myself the question: Are there some unintended consequences here that we need to explore? I think that this resistance to some elements of the harder part of training may be some of those unintended consequences.

I’m one of those brains that reads a lot outside of medicine as well. Joseph Campbell’s work, The Hero with a Thousand Faces, talks about this narrative architecture of the hero’s journey. Somebody is called out of their home, what’s comfortable. There’s this call to adventure, and then they leave. They meet increasingly complex challenges that frankly, when they begin their journey, they’re not ready or not equipped to overcome. But through the course of their journey, they meet friends who have maybe some different skills that they can learn from or that can be lent to these challenges. They meet mentors who may have some specific knowledge that they need, eventually building a skillset to where they can overcome a final ordeal.

If you think about any of the myths that we live with—Star Wars, Lord of the Rings, Harry Potter, any of those—they follow this arc. It felt to me like this might be a helpful narrative architecture to help our trainees frame their experience, the challenges that they’re meeting, in a way that actually redeems or ennobles the many sacrifices that are required of medical training along the way, in a way that might be more helpful than just thinking about work-life balances.

Kevin Pho: So what would be some examples or stories that you’ve observed, either through your trainees or from what you’ve seen, in terms of perhaps placing work-life balance at the apex at the expense of what you say are some important professional attributes?

Kevin C. McMains: Sure. I think one of the things I think about is that I’m a surgeon, and I realize that the obligation that surgeons feel towards their patients, and frankly, that is enshrined in our ethical codes of conduct, will enshrine a more longitudinal responsibility to patients perhaps than some other fields. That isn’t trying to throw shade on anybody else; it’s just the way that things are designed. I have oftentimes heard our residents realize only after the fact that they have not followed up on patients and have just tried to transmit or shift the responsibility for longitudinal care to other of their colleagues. There’s a degree to which that’s appropriate and fine.

There’s also a degree to which that watching both the development of pathology as well as people’s recovery from pathology, and seeing that at interval time points, is really the only way to generate the understanding of those diseases and the understanding of what normal, abnormal, worrisome, or not worrisome looks like. You just have to be there in some circumstances. That’s perhaps not a perfect example, but it is one of those things. There just isn’t a simulation or a YouTube video that people can watch that can give people all of what they need to be an excellent clinician and an excellent caretaker of other human beings.

Kevin Pho: And then when you bring this up, whether it’s through feedback or through general didactic sessions about the expectations, what are some of the responses that you have received?

Kevin C. McMains: It varies widely. Frankly, there are some people who I think are really open to this message and open to this notion. One of the things that I want to highlight about the hero’s journey is: you start, and you’re just not who you need to be at the end of your journey to overcome your ordeal. The analog is really effective for medical training. Any of us starting medical training are not yet the person or the professional that we need to become in order to take excellent care of people. For those folks who have an openness to that understanding, I think they can take that on.

I think there are many of us who have built an identity around excellence and about being a high performer that makes this a hard message to hear: the message of “you’re not yet the person that you need to be; you’re not yet performing at the level you need to.”

I know myself, I have historically been a pretty ego-defended individual. A lot of years of therapy along the way have helped me become more and more open to this, to where it feels less of an identity threat and more of an invitation to growth. The answer to your question depends on where people are in that journey as well, and their understanding of the need for ongoing growth.

Kevin Pho: So go into more detail about that narrative arc, that hero’s journey that certainly can reframe this issue.

Kevin C. McMains: It begins with a call to adventure, a leaving of the known. And then people will meet co-journeyers. You’ll meet different co-travelers. You’ll meet the different ordeals along the way. There are smaller tasks, smaller things to overcome along the way. There is the introduction of a mentor, maybe one or more, who has, in the language of Joseph Campbell, the secret knowledge or the sacred knowledge that can be delivered, eventually culminating in preparation for the hero for a final ordeal. And this to me is the exciting part: once they’ve been able to overcome that ordeal, they can return with the treasure.

If we’re going to apply this then to the journey of medical education, either undergraduate or graduate medical education, you have the call to adventure. You’re showing up, you’ve decided to pursue this, decided on your chosen field, your clinical field, your clinical specialty. There’s another element of this, which is a refusal of the call. Again, for those of us who are Lord of the Rings fans, you know that Frodo and Friends left the Shire, but who showed up in the immediate wake of that were the Ringwraiths. There’s real consequence to refusing the call. Where’s the analog here in terms of graduate medical education? We’ve all seen trainees of ours who just have a hard time making the required commitment. We had a trainee within the last several years who just decided that it was too much, that there were too many sacrifices that were going to be required of this individual. That individual wanted to live a different life. Fair place. She realized that she was on the wrong journey, that her path needed to go somewhere else.

Entirely fair. That’s different for everybody. But there are consequences to refusing the call. This individual chose a different path, but if we refuse the call and we don’t progressively develop these skills, we’re not going to generate the treasure. There’s going to be some loss. Personally, we’re not going to become the professional we might be able to become, but there’s also going to be some impact on our patients because we’re not going to be performing at the level that they need of us.

If we’re overlaying this on top of medical education, hopefully we meet co-residents who are supportive, who provide some of the skills, some of the insights that we may not have at the onset, whether those be people in our year cohort, senior residents, maybe even some of our juniors have some things that we need from them. Hopefully, faculty will serve in the role of mentors. Maybe other co-trainees will be in the role of mentors. Patients may be. There are any number of places that mentorship can come from to help frame what it looks like to take its seat at the table of professionals and ultimately overcoming this ordeal.

To my mind, it’s thinking about developing the body of expertise that’s required to masterfully practice as a clinician and then returning with the treasure. Whatever community people then leave training to become part of, they have something of worth that they can bring to that community, and that treasure that they have, that thing of worth, becomes something that enriches and beautifies the communities that they serve.

Kevin Pho: So it sounds like we have two ends of a spectrum, of course, where one places work-life balance at the pinnacle and the other way where medicine used to be, where medicine was a calling and you would sacrifice everything that you have for medicine. Is there a path in the middle that can address some of the issues on both ends of that spectrum?

Kevin C. McMains: I think it’s a terrific point you make. Part of what I resist about the characterization of work-life balance is that I think that it creates a false binary, that it sort of enshrines everything that happens inside the four walls of the hospital as negative, to be resisted. If we’re going to approach that from a strict critical theory that it’s just an expression of power that’s perhaps unjust, on the other hand, everything that happens outside the four walls of the hospital is nourishing and to be celebrated. I think that that draws those lines in an unhelpfully sharp distinction.

I think all of us can think about interactions we’ve had with patients that we’re proud of, skills that we’ve developed, procedures we’ve executed that we’ve done in a masterful way, emotional needs of patients that we’ve been able to address. Maybe we’ve only been able to address them because of some of the relationships and nourishing that we have from outside the hospital.

This notion of, “I can be a better clinician because of the deep love I have for my family and the commitments I have outside of the hospital.” There are some emotional resources that I can bring only because of those things and can meet that patient need. Similarly, there are some of the things that I do through work that energize me, that make me stand taller, that make me proud, that, again, make me come back and be a more loving husband, father, brother, son in those relationships as well. I think you asked the perfect question, which is about, I think the crux of it is this false binary that gets created by that work-life balance construction.

When we’ve talked about this, the tagline is, “A better story.” The hero’s journey is a better story for professional development, professional identity formation.

Kevin Pho: As you said earlier, everyone has a different journey, right? Everyone brings different values to the table when it comes to managing both their personal and professional life or how much satisfaction they gain from each sphere. Is it one size fits all? How can we change medical education to better fit and customize each individual’s journey, as you put it, or personal values?

Kevin C. McMains: You ask a terrific question, and I want to say just in general, the swing towards recognizing trainees as human beings over the last 20 years that I’ve been a faculty member is so radically different and, I think on balance, positive and ennobling.

That appreciation for trainees as individuals is a really helpful first step. The conversation that’s come up since the Flexner Two report around professional identity formation, and just what it means and trying to even initiate those conversations around what it is that we’re talking about when we talk about a professional in our field. There’s some good literature to show that that’s different from field to field. Internal medicine is going to look different from surgery, et cetera. But taking that then one step deeper or one step more granular to the individual trainee. Because one of the other things that is apparent through literature is that two people can go through the same set of circumstances, the exact same clinical experience, and those things can resonate in different ways and have radically different effects on their professional identity trajectory.

Being sensitive to that and us as faculty, particularly faculty leadership, leaning into those conversations as the potential mentor to the extent that our trainees welcome that and help navigate or narrate that in a way that makes explicit the things that we’re trying to role model and their responses to those interactions.

Kevin Pho: So on a practical level, how do you incorporate that hero’s journey framework when you talk to your trainees? How do you implement this? Is it through didactics, through one-on-one sessions you have with them? How do you frame that journey in the eyes of your trainees?

Kevin C. McMains: The answer is yes, all of that. I’ve had the privilege to have the opportunity to speak in front of larger groups, incoming interns, whether at the institutional level or at multiple institutions as well as at the individual program level. I love the opportunity to do those. I did one of those just three days ago.

And also at the individual level. Otolaryngology is really, in some ways privileged, but we’ve got such a small group. Our training program has three people a year, so we really do have the opportunity to have a longitudinal relationship with trainees that makes these sorts of opportunities more present than if I was just working with somebody as a one-off or perhaps one week at a time on a ward. We’ve got a luxury there.

It’s a luxury, but it’s also a responsibility, right? Because I talk about all this stuff and talk about the nobility of sacrifice, and if I don’t live into that, my residents are all smart and keen-eyed and they can see right through it. It in some ways forces me to a degree of integrity that pushes me to a better space to be a better professional myself.

Kevin Pho: We’re talking to Chris McMains. He’s an otolaryngologist. Today’s KevinMD article is “The hero’s journey: Understanding professional identity formation in graduate medical education.” Chris, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Kevin C. McMains: Both at the trainee level and at the faculty level, we’re on this journey of ongoing professional growth. Work-life balance as a construction has some limitations. One of the big ones there, I think, is the unintended consequences that come from this false binary. I think it’s really helpful to have a narrative architecture like the hero’s journey that can frame the sacrifices that each of us have to make to become the professionals we need to be in a way that redeems the sacrifices and ennobles that in ways that we can appreciate that and embrace that, knowing that it’s not going to be every day we’re going to have to make those sacrifices. We’ll hopefully be able to take a knee, take a break. But those things will nourish our capability to fill those other roles that we have to lean into and live into in our lives.

Kevin Pho: Chris, thank you so much for sharing your perspective and insight and thanks again for coming on the show.

Kevin C. McMains: Grateful for the opportunity. Thank you.