Published 5/1/2016
Richard Gross, MD

Contemplating Place and Power

More years ago than I care to calculate, I was among a group of college freshmen nearing the end of a fraternity "hell night." We were each given a candle and told to present it to one of the fraternity brothers assembled around us. Each of the fraternity brothers described a choice to which we could commit our efforts. I remember only one, which was actually one of the wrong choices, "place and power."

I remember that choice because we frequently discussed its meaning during the following days. We were virtually all from middle-class backgrounds, because children of privilege tended to migrate toward more prestigious institutions. In any event, we gave up on understanding what was meant by "place and power."

Two decades later, early in my career in academic orthopaedics, I had a revelation. I understood "place and power" and, with each passing decade, I understood why it was presented as a poor choice. As recent political campaigns show, seeking place and power exerts a seductive pull that tends not to bring out the best in those on that path.

Arthur C. Brooks, president of the American Enterprise Institute, recently tackled the issue in his column, "Rising to your level of misery at work" (The New York Times, Sept. 5, 2015). He described the interplay of place and power in this way: "Ambitious, hard-working well-trained professionals are lifted by superiors to levels of increasing prestige and responsibility. This is fun and exciting—until it isn't."

Mr. Brooks examined the phenomenon in depth and concluded that the best way to live life is by devoting it to the good of others, that service "reduces stress and raises satisfaction because it displaces the object of attention from oneself. … Adopting a service mind-set guarantees some measure of success."

Furthermore, the attitude of the worker is critical, as Mr. Brooks illustrated by referencing the parable of a traveler who met two stonemasons. When asked what they were doing, one said, "I am making a living," but the other responded, "I am building a cathedral."

I have known some people who rise to place and power and use their position and power to make a difference and "raise all boats" for those under their supervision. Unfortunately, many more individuals lose that perspective and forget that without those on the front lines doing their jobs in the trenches of life, they could not be where they are. The result is a dismissive mindset, and misery for those under their supervision.

Punctilious attention to metrics and outcomes is a 21st-century phenomenon that has consumed a great deal of time and energy in fields such as medicine and education. In a column for The New York Times, Robert M. Wachter, MD, interim chairman of the department of medicine at the University of California, San Francisco, addressed the impact of metrics in "hitting the target but missing the point."

Dr. Wachter quoted Avedis Donabedian, professor of the University of Michigan's School of Public Health, whom he called a "towering figure in the field of quality measurement." Prof. Donabedian was asked about his view of quality shortly before his death in 2000. He responded, "The secret of quality is love."

The word "love" is hard to find in current writings on medical practice or leadership. Without recognizing it, I learned about the impact of love in the 15 years I spent as an assistant coach on a high school soccer team. The effort was considerable, requiring that I juggle my work and practice to spend evenings at games, and making up the lost time whenever I could, to say nothing of the loss in income resulting from the time I spent coaching.

But I did it because I loved it. It kept me from rising to my level of misery. I learned what it was like to be part of a group that had a positive culture with shared values and that worked collectively to achieve excellence. The head coach established that culture, and, as Mr. Brooks predicted, the experience reduced my stress and raised my satisfaction.

This concept is often overlooked during the endless hours spent in medical institutions on "leadership training." The one failure I've observed over and over again, not only in hospitals and academic medical centers but also in organizations and industries, is the failure to achieve a positive group culture, something that can be made more challenging by work hour restrictions and other "established" components of medical practice and training, such as the relative value unit (RVU) standard for efficiency (and its role as a measurement of the financial value of a practitioner). A patient with a complex care problem is a real threat to efficiency and RVU production, especially if that care requires the physician to spend some time investigating the literature and/or conducting the history and physical. However, in my practice, some of my most gratifying experiences involved studying a problem without an established solution and finding a way to improve the outcome. Between that approach to medical practice and the time spent coaching, I've never made the median salary for an orthopaedic surgeon. I'm kind of proud of that.

In The Physician's Covenant: Images of the Healer in Medical Ethics, author William F. May argues that physicians have a covenantal relationship with society. Because society offers financial support for their medical educations and rewards for their work, physicians should feel obliged to repay society over the course of their careers. The opposite of a covenantal relationship is the contractual relationship. The contract is expedient, with limited obligations, conditions, and duration. It is external, in contrast to the covenant, which is internal and part of the individual.

Since that book was first published (in 1983), medical practice has evolved almost exclusively into a contractual model. Service and love cannot thrive in contractual models. Yet Dr. Wachter and Mr. Brooks clearly make the case that contractual thinking cannot sustain one over the course of a career; both note the current prevalence of burnout and career dissatisfaction.

Will their voices be heard? It's hard to find anyone who is listening right now.

Richard Gross, MD, is a research professor in the department of bioengineering at Clemson University. He can be reached at grosshr@mac.com


  1. Brooks AC: Rising to your level of misery at work. The New York Times, Sept. 5, 2015.
  2. Wachter RM: How measurement fails doctors and teachers. The New York Times, Jan. 16, 2016.
  3. May WF: The Physician's Covenant: Images of the Healer in Medical Ethics. Philadelphia, The Westminster Press, 1983.