A Mysterious 19th C. Primer on Surviving a Medical Career

“Nobody wants to swim with sharks. It is not an acknowledged sport, and it is neither enjoyable nor exhilarating.”

So begins an essay by Voltaire Cousteau, an obscure French writer who may have penned “How to Swim with Sharks: A Primer” in the early 19th century, possibly for sponge divers. We say “may have” and “possibly” for reasons we’ll discuss.

The essay functions as arch instructions for dealing with toxic individuals, and the message has resonated with the medical community. In fact, this work of mysterious origin has become something of a legend at many med schools around the country. UPenn Perelman School of Medicine, Philadelphia, for example, makes the essay available to new students.

“The metaphor is that the attending physicians are the sharks and that the interns are the swimmers,” wrote Betsy Grunch, MD, a neurosurgeon from Georgia who was introduced to the essay during her residency.

She wasn’t empowered by it. The shark-swimming rules “promoted toxicity in healthcare,” she said. That toxicity caused so much emotional turmoil among Grunch and her peers that one of her fellow interns took his own life in a nursing storage closet.

The essay brings into sharp relief the dichotomy in medicine where some believe becoming tougher is critical to the job and others believe sharks should grow up and learn how to swim without using their teeth.

A toxic workplace environment is nothing new in medicine. “Voltaire Cousteau,” a supposed ancestor of Jacques, certainly knew this, as did Richard Johns, the founder of the Biomedical Engineering Department at Johns Hopkins, Baltimore, who gave the essay as a “dinner talk” in 1974, and is likely the hinted-at “author.” Provenance notwithstanding, the essay’s purpose is clear and resonates today.

What has changed in 2025 is that more people are speaking up and sharing their stories. Like Kellie Lease Stecher, MD, an OB/GYN from Minneapolis, who says that during the early years of her career, almost a decade ago, she quickly learned that growing a thick skin to constant hostility was indeed part of the job.

“I’ve been in rooms with male colleagues, where we’re sharing ideas, and when I try to interject, I’ve been shushed and snapped at and had my body talked about in demeaning ways,” Stecher said.

The problem with the “get tougher” school is that, yes, being more resilient can make you better at handling the stress and trauma of being a doctor, but the unspoken reason to get tough is so toxic behavior in the establishment can continue without consequence.

Stecher learned that trying to bring up these uncomfortable encounters with administrators was almost always greeted with indifference or even anger. “We were always shamed into thinking it was our fault, or we were just playing the victim,” she said. “All I wanted to do was show up and do the best I could and take up the space that I’d earned. But it was really frowned upon to say even one negative thing about the work culture.”

In 2022, she was fired from her hospital in Minneapolis after reporting a patient’s allegation of sexual assault by a male doctor. Stecher landed on her feet — today, she works for Minnesota Women’s Care, Maplewood, Minnesota — but while she feels protected and respected in her current position, she isn’t convinced that much has changed in the medical community.

“Most of us got into healthcare to help people,” she said. “It’s not just a product we’re putting out there. It’s about people’s lives. But unfortunately, a lot of times, that comes into direct conflict with the business of medicine.” When a hospital or medical facility is run like a corporation, with a “get the job done or heads will roll” mentality, “it brings a lot of moral incongruity for a lot of physicians,” Stecher said. “And when you try to make a change, you become the problem.”

Since 2018, more than double the number of healthcare workers have reported harassment at work, both from colleagues and patients, according to the Centers for Disease Control and Prevention. And the harassment runs the gamut from threats to verbal abuse to outright bullying.

Gail Gazelle, MD, agrees that the situation isn’t new but thinks the toxic dynamic has become exacerbated in the post-pandemic world. “The healthcare system is really stressed,” she said. “And that does not bring out the best in people.”

Over the past few years, she’s turned her focus to life coaching, teaching resilience and mindfulness to internal medicine residents at the Brigham and Women’s Hospital in Boston. There’s a term she uses when explaining how medical professionals often respond to repeated disrespect: Lateral incivility.

“When people are stressed, when people feel unvalued, when people have more to do but have less resources and less time, sometimes they not only don’t help each other out but actually go out of their way to make things more difficult for others,” Gazelle said.

Gazelle’s seen (or, with her workshop students, heard) many examples of this, and it’s almost never the classic definition of bullying. Sometimes it’s an anesthesiologist feeling rushed by a surgeon and taking it out on her Certified Registered Nurse Anesthetist. Or are nurses resentful that they’re the ones delivering radiation to patients with advanced cancer and not the radiation oncologist? “If the staff feels undervalued, or they’re upset that a doctor earns four times what they make, they might walk a little more slowly during their shifts or make a little less effort than they could, just to make that doctor’s life difficult.”

That antagonism, subtle or otherwise, can also come from patients, “some of whom may be dealing with the worst news of their lives,” said Mikkael Sekeres, MD, MS, a chief of the Division of Hematology at the University of Miami, Miami. “They may not have the coping tools to successfully navigate that news.”

And that illustrates the line between toughening up to handle the job — serving patients in distress — and toughening up so colleagues don’t have to answer for lousy behavior.

The abuse usually starts early, in medical school and residencies, which are focused on “training to take orders,” said Stecher. “Healthcare is a very hierarchical institution, much like the military, and physicians are expected to follow the line and be obedient. We get hardened to it, and we take it for granted. This culture of shame and blame is bred into us from the beginning of our education, and when it happens enough and nobody speaks up or objects, it becomes normalized.”

Because it’s so ingrained in the culture, and students learn to take it rather than complain, many medical professionals go years and sometimes their entire careers without acknowledging a problem.

Gazelle recalls meeting with an emergency physician who’d come to her for coaching after finishing her residency and was unsure why she felt so miserable. “She told me, ‘I come to work every day, and I don’t want to be here. I’m really questioning my career choice, not just emergency medicine but healthcare in general,’” Gazelle said. When she pressed the physician for more details, she told Gazelle, “Everybody is so stressed all the time. I see them in the nurse’s station between patients, and nobody is talking. They’re just taking notes and avoiding eye contact.”

Another reason people have a hard time speaking out is there’s rarely a specific, glaring wrongdoing. It’s not always sexual harassment or physical violence. More often than not, it’s microaggressions, Gazelle said, “based on race or gender or sexual preference or religious beliefs or beliefs about science or COVID or politics.”

“Healthcare is really just a microcosm of society,” Gazelle said. “Doctors, at the end of the day, are just people.”

If Cousteau/Johns’ essay really was written in 1974, the medical ocean was populated by different species of sharks and swimmers, and as you see in some of the quotes here, the advice in modern context runs from clever/ha-ha to obtuse. Should there even be sharks in 2025 waters?

Sekeres believes meaningful change has to start at the top. “There needs to be an authority figure, be it a department chair or cancer center director, who embraces a zero toxic culture, and makes it known that there is no excuse for any behavior that can be interpreted as angry or toxic,” he said.

Stecher agrees. “You need a workplace where the leadership is willing to stand up for their staff, who make it obvious that they’ll protect their employees and patients and hold people accountable. If they don’t share those values, it’s a short path to burnout and frustration and anxiety.”

That kind of seismic shift is easier said than done, especially when it affects the bottom line. “They (hospital administrators) always have their own motivation,” Gazelle said. “Maybe they need that leader, even if he or she is being a bully.”

That leaves it up to the swimmer to swim, as it were, even if the sharks are gonna shark. Rather than waiting for real systemic change or “some kind of top-down solution that’s probably never going to come,” Gazelle said, she suggests that the healthcare system could be fixed “with each of us thinking about how we show up each day.”

Direct confrontations aside, Stecher is adamant that medical professionals need to be more serious about protecting their own mental health. “Everyone needs to check in with themselves and recognize when they’re frustrated or upset by a situation. A lot of us go through life taking care of patients, and we ignore what’s happening in our own heads, and the resentment builds and builds until it suddenly flares up. That’s not healthy for anybody.”

For all the training that doctors and nurses get in the field, they’re almost never instructed on how to “monitor their own emotions,” said Stecher. “And that can be really critical.”

It doesn’t have to be a grand gesture, said Gazelle. And it doesn’t always have to be about ourselves. “Sometimes it’s the small things, like reaching out to a colleague who’s clearly having a bad day and saying, ‘Are you okay? How can I help?’ That’s such an act of community, an act of civility, an act of caring,” she said.

When those around you feel less alone, they’re more likely to pay closer attention to you when you’re showing signs of mental distress. “Isolation fuels a lot of this incivility,” said Gazelle. “And that starts to change when we appeal to the better nature of other people.”

Something Gazelle asks herself every day: How am I showing up today? Am I being respectful to other people? And if I feel like I’m being treated badly, am I then treating others badly in response?

“Because in the end, that’s all we can really control,” said Gazelle. “We can’t control the bullies. We can’t force them to change or treat people differently. But we can control how we respond to them.”