Dr. Holmboe, thank you for your time. Over the last few years, I have found myself using the term “nostalgialitis imperfecta profunda” more and more. It’s a term I learned from you, and it seems to perfectly encapsulate a difficult-to-describe condition that is pervasive in medicine. I wanted to ask you a few questions about it for the ICE blog community.
What exactly is “nostalgialitis imperfecta profunda”?
ESH: Simply defined, it is a tongue-in-cheek, latinized and medicalized way of saying someone has a profound and imperfect nostalgia (i.e. profoundly imperfect recollection of or yearning for the past). It is a well-known phenomenon our memories can be flawed and actually change over time, including remembering things more favorably than they actually were. Malcolm Gladwell actually did a podcast on this phenomenon.1 Nostalgialitis imperfecta profunda also plays into the identity issues of self-image and power, and not always in good ways.
How did this term come about? Do you remember how/when you first applied it? Has it evolved over time?
ESH: I honestly cannot remember exactly when I created the term, and as I said above, it is not a new concept. The catalyst, however, was the intersection of two observations. First, when I, along with other colleagues, attempted to make a change in a training program, or implement a quality improvement intervention, we were met by the typical resistance that often accompanies change. However, I was struck that the individuals pushing back on why we shouldn’t make a change often referred back to their own training in favorable terms (or in the case of QI, that they were already using evidenced-based practice and that they had been “well-trained” regardless of where they trained or how) as proof things were fine (“after all I turned out OK, right?”) – their n of 1 experience was evidence that change was not needed and could actually be harmful. So, part of nostalgialitis imperfecta profunda gets wrapped up in self-identity. I later read a book by Heifetz and Linsky, “Leadership on the Line” that made the brilliant observation that change isn’t really about change, it is about loss, including loss of identity and sense of self-worth.2
This is my interpretation of what a number of my colleagues experience in medical education when presented with the need, or opportunity, for change in medical education. This sense of loss can often be exemplified by this real-life example I had ten years ago with several colleagues: “are you saying that what I have been doing for 25 years as a program director (of clinician-educator, etc.) is no longer good enough? I have dedicated my life to medical education, and I think by now I have a pretty good idea of how to run an effective program (or teach effectively, etc.).” I have had conversations with some of individuals some years later where they realized they were in fact experiencing loss.
The second observation was more troubling and sinister. Specifically, the sport of trainee bashing based on generational differences. I am deeply troubled by such behavior and continue to see it regularly. You know the rhetoric:
- Trainees today are less committed and more interested in their lifestyle.
- Trainees are less professional, always on their phone, etc.
- Back when I did residency, we didn’t have duty hours, and as a result I did more cases and came out much better prepared.
- Trainees today do not know what hard work is as a resident…back when I was a resident…
- Add your favorite…I could go on.
What is disturbing is there is very little evidence that folks of my generation (I’m a “boomer”) were “better.” The system at the time suffered from gross under supervision. Errors were normalized as part of training, often expressed as “if you haven’t had a complication, you have done enough procedures.” Worse yet, we did not have the measurement capabilities we have today, meaning we often could not even detect when we were causing harm. Proof of this would later come from the 1991 NEJM Harvard Medical Practice Study that found an alarming rate of harm and error in a series of hospitals in New York state.3 This large study would serve as one of the backbone studies for the IOM Crossing the Quality Chasm and To Err Is Human reports.4,5 Furthermore, John Wennberg and colleagues at Dartmouth had been discovering uncovered substantial practice variation in Vermont and Maine in their seminal studies between 1973 and 1990, with much of that variation due to differences in physician decision-making.6
Here’s the kicker: The data for the Harvard Medical Practice Study3 was collected in 1985 – the year I graduated from the University of Rochester, in New York!
Finally, I just find this generational trainee bashing deeply unprofessional. Worse yet, it is primarily my generation that has put students in incredible and unsustainable levels of debt, created a healthcare system collapsing under its financial weight, failed to adequately transform the medical education system to truly enable better educational outcomes, and have tolerated, or worse inflicted, indefensible levels of burnout, harassment, misogyny, inequity and bias that continue to plague our young learners.
The term seems to resonate with a lot of healthcare professionals. Has anyone been offended upon hearing it?
ESH: My sample is obviously biased, but interestingly no. It usually gets a laugh and a nod “yes.” It may be that by creating a quasi-latin, medicalized term for the syndrome helps to disarm reactions and concern around the concept and topic. My theory, and other literature supports this, is that humor can sometimes help to broach a sensitive subject in a less threatening way.
Are there any telltale signs of nostalgialitis imperfecta profunda setting in?
ESH: Easy. Anytime someone starts to defend a position or is resisting a reasonable, evidence-based change by quoting something form their past experience without any evidence, or at least an evidence-based alternative, to back up their contention is slipping into nostalgialitis imperfecta profunda. I do want to point out there are in fact past educational behaviors that are evidence-based and should still be used (e.g. bedside rounds, direct observation; patient-centered care, etc.). The second telltale sign – any form of generational learner bashing.
In your experience, are there any risk factors for developing nostalgialitis imperfecta profunda? Are some people more susceptible/protected than others?
ESH: The obvious one is age (and I can say this as someone now in the latter stages of my career). Thomas Kuhn in his classic 1962 Book, The Structure of Scientific Revolutions, highlighted how older scientists struggle to evolve beyond their current paradigm as they have spent much time working and defending it.7 I also believe that the nature and conditions of the past experience are important and often have profound impact, including the socialization process that occurred during the individual’s training. (I recommend Charles Bosk’s classic book Forgive and Remember8 ). After all, the nostalgia emanates from that past experience. Other factors include, frankly, arrogance and rigidity. Medicine still suffers from a profound lack of humility in too many settings. Finally, reflective practice and insight (especially the lack of these skills) matter a lot. Finally, another factor is whether the individual has a growth or fixed/performance mindset (see Carol Dweck’s work9). Those with a growth mindset, in conjunction with humility and a curious mind, are protected from nostalgialitis imperfecta profunda.
“itis” means this is a pathologic condition, which suggests there may also be a treatment. How does one remedy nostalgialitis imperfecta profunda?
ESH: Yep! Treatment of nostalgialitis imperfecta profunda depends on the primary pathology. If it is mostly around resistance to change, then it is important to uncover and deal with the individual’s sense of loss. In essence, help them through the grief reaction. Treatment also requires patience and meeting the individual where they are through listening and conversation. Facts alone do not work, but facts still matter. It will be a series of conversations and also giving the individual a meaningful role in the change.
When it involves learner bashing, especially when bullying, bias, etc. are involved, then you are dealing with a professionalism spectrum disorder. Some can be classified as “lapses”10 which can be dealt with through 1:1 conversations and feedback (akin to the Vanderbilt model for dealing with disruptive physicians11). When it becomes more egregious, you are dealing with “on-off” behavior and individuals of higher authority need to be involved.
Postscript – COVID19
ESH: The full and profound impact of the COVID-19 pandemic began occurring after the initial submission of this ICE Blog. I will simply say this: the actions of our current health professions trainees are deeply humbling and nothing short of amazing. To those who have and continue to serve during this pandemic, you have my deepest gratitude. I send my condolences to those who have suffered loss. Our learners now enter a totally changed world and disrupted, struggling healthcare systems. Let’s all make it our sacred duty and moral obligation to ensure they receive the support and respect they deserve, now more than ever.
1. Malcolm Gladwell. Revisionist History Podcast. Free Brian Williams (Season 3; Episode 4). Accessed February 7, 2020 at http://revisionisthistory.com/episodes/24-free-brian-williams.
2. Heifetz RA and Linsky M. Leadership on the Line. Staying Alive through the Dangers of Leading. Harvard Business Review Press. Boston. 2002.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324(6):370–376.
4. Institute of Medicine. Crossing the Quality Chasm. A New Health System for the 21st Century. National Academy Press. Washington, D.C. 2001.
5. Institute of Medicine. To Err Is Human: Building a Safer Health System. National Academy Press. Washington, D.C. 2000.
6. Wennberg JE. Tracking Medicine. Oxford University Press. New York. 2010.
7. Kuhn, T. S. The Structure of Scientific Revolutions. Chicago: University of Chicago Press, 1962.
8. Bosk CL. Forgive and Remember. 2nd University of Chicago Press. Chicago. 2003.
9. Dweck CS. Mindset. The New Psychology of Success. Random House. New York. 2006.
10. Ginsburg S, Regehr G, Stern D, Lingard L. The anatomy of the professional lapse: bridging the gap between traditional frameworks and students’ perceptions. Academic Medicine. 2002;77(6):516–522.
11. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine. 2007; 82: 1040-8.
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