Joy and the ACGME Common Program Requirements

In 1982, John H. Stone III, MD, a cardiologist-poet, addressed the graduates of Emory University School of Medicine with these words:

“For the heart will lead

For the head will explain

but the final common pathway is the heart

whatever kingdom may come

For what matters finally is how the human spirit is spent

For this is the day of joy

For this is the morning to rejoice

For this is the beginning

Therefore, let us rejoice”

—Gaudeamus Igitur¹

The title of this address, Gaudeamus Igitur, means in Latin, “Therefore, let us rejoice.” It is the first line of a medieval hymn that was sung for centuries at European university commencement ceremonies. Its origins date back to the 13th-century tradition of singing celebratory, sentimental, sometimes bawdy drinking songs upon graduation. The tradition of Gaudeamus Igitur is also known as the De Brevitate Vitae, “On the Shortness of Life.”¹ Dr. Stone's poem has spoken to me over the years as I've experienced our grand traditions in medicine—of the tension between heart and head and of the importance of joy in our calling.

In reviewing the revised Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements, I caught these words tucked after the section on resident evaluation: “Residency education must occur in the context of a learning and working environment that emphasizes the following principles . . . the joy of curiosity, problem-solving, intellectual rigor, and discovery.”²

That word joy leaped off the page, a pleasant, curious surprise. Joy is a loaded word, one that usually finds its home in the lines of poetry and Scripture. Joy is mentioned 165 times in the Bible, about the same number as grace at 170 times.³ According to the Oxford English Dictionary,⁴ the word joy comes from the Old French joie, which in turn came from the Latin gaudia, which inspired Dr. Stone's commencement address. The dictionary defines joy as “a vivid emotion of pleasure arising from a sense of well-being or satisfaction; the feeling or state of being highly pleased or delighted; exultation of spirit; gladness, delight.”⁴ And so, there it is—joy. Amid duty hour regulations and Clinical Competency Committee (CCC) requirements, joy is now officially an ACGME requirement.

I confess to having several reactions. I applaud the ACGME for being so bold as to issue such a charge to medical educators. Nothing sets an agenda better than an ACGME requirement. Look at work hours, milestones, and expectations for CCCs. We adhere to these requirements precisely because they are requirements; but also, for the most part, they are robust concepts and “good ideas.” Indeed, the other requirement in the same section is equally daunting: “the effacement of self-interest in a humanistic environment that supports the professional development of physicians.”² I am chagrined that at my next ACGME site visit, the evaluator might ask me, “Dr. Doolittle, in your program, how do you foster a culture of joy? How have you effaced your self-interest?”

What would I say? Can we mandate joy? Will joy work its way into the milestones? It all seems a bit odd. In medicine, we cherish our traditions—the white coat ceremony, the Match, grand rounds, the “pimping” of medical students, and even the sign-out at the end of a shift. Could we actually instill a tradition of joy? How do we do this? To quote Dr. Stone's poem, “For joy is nothing if not mysterious.”¹

The ACGME requirements give us some guidance: “excellence in professionalism through faculty modeling.”² This is both supremely disheartening and ultimately encouraging. In addition to work hours, CCC roles, faculty evaluations, and requirements for ambulatory clinic, we are expected to model joy? At a time when the prevalence of physician burnout is 54%, this may be the most challenging ACGME requirement to date.⁵ And yet, ACGME requirements drive the dialogue in medical training. What better way to foster joy than to require it—especially among goal-directed, check box–oriented program directors? I am struck that this requirement reads not so much like a requirement but more like a manifesto to change the very culture of medicine.

Dr. Stone's poem also reads,

“For there are all kinds of

all degrees of joy

For love is the highest joy

For which reason the best hospital is a house of joy”¹

May it be so.