Imagine starting a new job with very little orientation, on the busiest service (cardiac surgery), with minimal supervision from a disgruntled cardiac surgery fellow (who barked instructions while speed walking through morning rounds), and knowing that you would be in the hospital at least 36 hours from the time you walked in the door because you were on call. My worst fears as an intern were realized that day. After he left to go to the operating room for the day, I looked at my list and realized I did not know how to accomplish 1/2 the things that were on it. I felt like I was doomed to failure and would be looking for a new job the following day.
I also knew that first impressions mean a lot in the world of medicine and that failure to accomplish the tasks at hand would be viewed as a sign of weakness. If I had the label of weak and incompetent attached to me early on, I might make it through training, but I would not be given the same opportunity as those who were viewed as capable and strong. I was in a bad place.
However, it was not a place that I was unfamiliar with and I suspect it is a common experience for anyone reading this who completed surgical training or rose up the ranks in any high pressured field. You would think that medical school would prepare you for the rigors of internship. While I felt confident about my medical knowledge (misplaced confidence), I had very little knowledge of how to get things done in my new environment. Every service, hospital ward, Department, etc… is its own micro-environment with its own way of doing things and its own set of rules. Fortunately, successful medical students are very familiar with this. Every 1-3 months as a medical student, you rotate to a new service and learn the unspoken dynamics between the attendings, residents, nurses, and other medical staff. You learn what drives the culture of the group. And you learn to exploit it to be successful in that environment.
And that is exactly what I did on my first day. I quickly went down my list and accomplished the easiest, most straightforward tasks. Along the way, I began to get a lay of the land. I was friendly and spoke to anyone who would speak to me. As I started putting charts with orders into the chart box, I struck gold with the Unit Clerk. She had worked there for over 30 years and could have been my grandmother. And being a young looking 25 year-old, she treated me like her grandson.
She told me to sit down and for the next 30 minutes described how the morning, middle of the day, and afternoon/evening worked for the cardiac service. She told me all the tasks that were supposed to happen early on (check labs, write orders, write notes), when to pull the chest tubes, who to talk to in radiology to get my x-rays done first, when each attending surgeon would come up to the floor and round and whether they wanted me to walk around with them or wait until they were done to see what they wanted for their patients. She told me how to prioritize discharges and who to talk to if I was having trouble getting patients out.
It was like a fly wheel. Once I started acting on her advice and patient care was moving forward, other people began to help. The nurses would bring the charts to me to write orders, the social worker paged me and helped me deal with a difficult discharge. The pharmacist helped me make adjustments to a TPN order. I might not have had a chance to go to the bathroom or eat something, but by the time my fellow came up to round in the evening, I had accomplished all the tasks set out in front of me. I felt that I had achieved success!
Well my feelings of success were completely crushed as we rounded on each patient and my fellow yelled at me for either not doing something or making an incorrect decision (based on his view). By the end of rounds, I had the same sized “to do” list as I had in the morning to accomplish by the following morning when we would do it all over again. I started to frantically go down my list and get things done- draw labs, track down x-rays and records for surgery the next day, write orders, and check on patients who needed extra attention. Half-way through this, I began to get sign out from interns on the thoracic and other cardiac service (transplant) which only added to my list. To add to this, I began getting pages from nurses asking me to respond to atrial fibrillation, constipation, diarrhea, pain, delirium, and a laundry list of other issues that seem to rear their ugly head when the sun goes down.
I survived that night (and so did my patients) through hard work, sheer determination, a little luck, and being as nice as I could to anyone I came across that might help me at the time or later. It worked. I survived that night, the next day, month, year, and subsequent transitions in my career using the same tools I learned in medical school and residency. People around me have come to expect that I am willing to work hard, not complain, try to be nice, willing to help my friends, family and colleagues, and often prioritize organizational goals above my own.
In general, most people would say these are good characteristics to have. But every silver lining has a cloud. The problem is that people assume that this is who you are, expect that you will always behave in a certain way, and react when you do not perform in a way they expect. Most of us go along with these expectations because these behaviors have been the secret to our past success. In acting, they call this being “type cast”. Actors are given the same roles to play over and over again because they do well with them and fellow actors, directors, and the public associate them with a particular type of character. We can all think of actors that fit this bill.
Similarly, I believe if we all stopped and reflected that we, like actors, are type cast into a particular role, a certain set of behaviors, and defined expectations. As time goes on, we adopt that role as our true self. It may be who we are but it leaves little room for who else we may be as well. If you have had unconscious bias training, you might be thinking about this discussion in that context. The difference here is that being type cast requires both others and ourselves to make assumptions about us. Unconscious bias often takes place when we encounter people we don’t know but make assumptions about them based on how they look, behave, speak, and any number of cues. Type casting is a bias that develops that is shared by those who know us and our own self. But just like an actor who is type cast, living a type cast life has drawbacks.
I have come to understand that being type cast in our lives has several drawbacks. The tools and behavior that help us to perform well in certain environments may not be effective or may even be counterproductive in other environments. The most dramatic example of this is soldiers returning home from war. The behaviors that keep people alive during combat are not conducive to family life. Similarly, the behaviors that make someone a good intern do not necessarily make somebody a good parent, spouse, or partner. It can be challenging to transition back and forth between different social expectations. A great deal has been written on this subject and I will not pretend to be an expert. From a career perspective, the behaviors that make us successful professionals do not necessarily prepare us to assume leadership or other roles as we evolve in our careers.
On a more personal level, being type cast can cause emotional and physical harm. The expectations and social norms of those around us that we take on as our own, may not be true to ourselves. Fortunately, our world is changing but not fast enough to prevent some from suffering under the yoke of these expectations. Again I am no expert here and I am fortunate that I have not had to live a lie. But many people continue to do just that. They are forced and accept the lie of sexual orientation, gender identity, body image, career direction, love, ideology, oppression, physical restrictions and countless other social and cultural norms that tear at some peoples’ souls to the breaking point. Living these lies can make people mentally and physically ill. While I accept that there are certain societal boundaries and cultural norms that we need to live within to coexist with each other, I believe that at least here in the United States that the ideas outlined in the Declaration of Independence of life, liberty, and the pursuit of happiness should be provided to all of us and we should all aspire to help our fellow human beings live in a world where this is possible.
I want to mention one more point although I am sure there are other reasons why type casting in our lives is harmful. The roles that we assume to function and thrive in a particular environment limit our possibilities. This is not merely the possibility of career development/advancement that I discussed above. This is the type casting that prevents us from exploring other roles, other aspects of who we are and who we may want to be. This point is interrelated to my first two points. The limitation on our horizons begins early in life as those around us define our opportunities, strengths, and weakness and we integrate these into the fabric of who we are. Our lane becomes defined and over time as we adhere to this lane, it becomes narrower and straighter. The potential societal cost to this is huge. When we fail to provide others the space to explore who they are and what drives them, we may miss the next scientist who will help us establish human life on Mars, or a great teacher, doctor, parent, or friend. We lose the next best song, novel, or poem. Poverty, injustice, and social determinants likely have a greater impact on missed potential but providing people space to explore is much lower hanging fruit to fix that might give our society the next scientist or leader that will help us solve a major challenge.
The first step in tackling this is for all of us to acknowledge that this exists. A phrase that is driving me crazy right now is, “Stay in your lane, bro.” Its problematic for two reasons. Not only is it a nice way to say shut up and mind your own business, it also has the implication that people need to stick to a particular path. The second step to addressing your life if you feel like you have been type cast is to do something about your lane. You don’t necessarily need to change lanes and risk crashing into somebody else but you can work to expand your lane, take the next exit off the highway and take the back roads, or change lanes if that is what you need to do. You can even make a U-turn and change directions. For me, writing this blog is an element of changing lanes. I feel very fortunate that I have a life of meaning where I help to alleviate suffering and treat cancer. But this blog gives me an opportunity to do something for myself. If nobody reads this, that would be just fine with me because writing this has given me the chance to explore outside of my lane.
Some of you reading this might think that you are not type cast and you may be right. The test question to ask yourself is how often you feel guilty or anxious about not doing something or performing in a certain way. If your answer is rare, you are probably in pretty good shape. If your answer is often, then you may be type cast in your role in life. While it is true that my family very effectively used guilt to set expectations, if you’re grown up now, you need to overcome these chains. If you are a physician/clinician, our roles are increasingly being type cast. Expectations and pressures to perform and function in a certain lane are coming from both the lanes around us and oncoming traffic. The data on patient satisfaction is mixed but organizations and payers are increasingly tying compensation to these measures. Our job as clinicians is to keep people safe, heal them (or alleviate suffering) and be nice to them in that order. It is not to give them want they want especially when it is contrary to scientific evidence or best practices. Forcing clinicians to perform this role is bad for us and our patients. I have fought this role by having honest conversations with patients and setting reasonable boundaries to what I am willing to offer. Patients should have education and choice when it comes to their treatment but my clinic is not Burger King; I don’t have to do it your way.
I want to leave you with an excerpt that I believe summarizes my discussion much more eloquently than I can. As Jacques spoke in William Shakespeare’s “As You Like It”: All the world’s a stage, And all the men and women merely players; They have their exits and their entrances; And one man in his time plays many parts…