How the restaurant drama ‘The Bear’ mirrors working in a hospital

Many chefs describe the television series “The Bear” as an accurate portrayal of the demands of a restaurant kitchen. I believe it can also be seen as a characterization of work in a hospital, in which future physicians are simultaneously gaining remarkable skills and enduring career-altering abuse.

For my new book, “Progress Notes,” I spent a couple years observing seven medical students in an experimental curriculum. As they examined patients and learned from physicians in clinics, operating rooms, and emergency departments, I saw them shaped by positive experiences. Gracious words from patients and encouraging comments from the faculty drew them towards a specialty. I also saw students opt out of specialties because they had been mistreated, just I had been during my own training two decades ago.

Every year, when the nation’s 20,000 or so graduating medical students are surveyed by the American Association of Medical Colleges, about 40% report personal mistreatment during medical school. Yet fewer than 25% of them had reported this to a faculty member or administrator, perhaps because faculty members and residents are the people most likely to mistreat students. In a related study, more than half of graduating students describe the behavior of faculty members and residents as negatively influencing the specialty they choose in “the Match.”

“The Bear” dramatizes those choices. The show is set in a Chicago restaurant where the lead chef is a demanding perfectionist whose remarkable meals and angry outbursts alternately attract and alienate co-workers. It’s a tense watch, leaving viewers wondering why high cuisine comes with high anxiety. As a physician, the restaurant reminds me of a hospital: team-based but hierarchical, high effort but ephemeral labor, high skill but a version of a core human activity.

The show also mirrors the generational conversations going on in medicine: The lead character, Carmy, has inherited the restaurant from his older brother Mikey, who died by suicide. Mikey is like a tragic Gen X doc who never finished residency and wound up working as a general practitioner in the family medical practice. It cost him his life, but he left behind a building, a mantra, and an operating room playlist. Cicero (also known as Uncle Jimmy) is like a Boomer doc who got in early, made his fortune, and could retire but can’t quit because he loves his role. Sydney, the new addition to the cooking team, is like a Gen Z doc swamped by debt who has all the ability but not enough of the credentials or capital. Richie, who was Mikey’s best friend, is like a Gen X med student who failed out and, even though he has achieved success in other health care work, he resents doctors. Tina, a chef at the restaurant, is like a Boomer resident who wanted to enter formal training decades ago, never got a fair shake, but kept working and somehow kept her enthusiasm alive and is now having her moment. Sugar, Carmy’s sister, is like the Gen X doc who takes on all the administrative roles — billing, credentialing, licensing, and the like — so everyone else can keep working. And Marcus, a baker at the restaurant, might be a Gen Z med student who rediscovers the curiosity, humility, and care we all need.

Since the pandemic, the generational changes within medicine have begun creating a rupture within the profession. While medical schools are growing in number — 15 new allopathic and thirteen new osteopathic schools have opened their doors since 2014 — they are struggling to find enough of America’s 1 million practicing physicians willing to teach. Physicians in the field are pulling back from medical education because they are too burned out, too busy, or too confused by today’s students. Medical students continue to enroll, but are now asking existential questions about why medical training is so costly, time-consuming, and dehumanizing.

The generational differences have grown so prominent that The New England Journal of Medicine hosts an article and podcast series on the divide. The host, Lisa Rosenbaum, a cardiologist at Boston’s Brigham and Women’s Hospital, interviews physicians from every stage and generation. Steering clear of simple-minded “kids these days” explanations, Rosenbaum explores why medical trainees report being broken down instead of being built up, how endemic burnout resists wellness efforts, how educational debt alters choices, why faculty members aren’t able to provide honest feedback to trainees, and how interest in self-sacrifice has declined among physicians. Rosenbaum says it amounts to a quiet revolution in medical training.

For many of my friends in medicine, the loudest part of the revolution are the tears. I know physicians who describe listening to Rosenbaum’s podcast as a kind of therapy. They listen to it to on the way home from the hospital, sobbing at stoplights as they reflect upon some generational conflict with their trainees. When they get home, they forward an episode to other docs. For academic physicians, the podcast validates their experiences, much as “The Bear” does for chefs.

It’s hard to imagine Carmy, the protagonist of “The Bear,” forwarding a podcast. He barely answers his phone because he is so caught up in his work. Carmy can charm, but is often anxious, like a millennial doctor who earned all the credentials and exceeded his family’s dreams but can’t escape himself. He embodies all the burnout and moral injury in medicine, but also the way medicine has failed its trainees.

I suspect the doctor who changed my career path embodies them as well.

When, as a third-year medical student, I was assigned to work with him, he was the chief resident. All the attending physicians described him by his test scores — they are the highest in the nation! — and all the nurses described him by his behaviors — he has the lowest in the hospital! This high-testing, low-behaving surgeon would strut about in scrubs a size too small to show off his muscles, approach nurses from behind to deliver uninvited backrubs, and yell at medical students, usually at the end of a merciless caricature of the Socratic method known in medical education as pimping.

I shared his operating room for a patient with pheochromocytoma, a tumor of the adrenal gland. He showed me how to move a scalpel and retractor blade through the body so we could visualize the tumor perched on the gland. I tried to follow his moves. He told me his moves were “textbook,” while mine were “fakebook.” He reached his assessment early: “You will never be a surgeon.”

I stayed silent — never easy for me — but a sudden thought made me realize that would be fine as long as it meant I would never be anything like him.

“What kind of doctor will you be?” he asked me.

“I was thinking surgery, now maybe psychiatry,” I replied.

“Then you must know the catecholamine degradation enzymes,” he said.

“I used to,” I mumbled.

“Tell them to me in order,” he demanded.

I fumbled the first one. He flicked the dull end of his scalpel forward, out of the patient’s body, and onto my gloved knuckles. I was taken aback, but held onto the retractor. He asked again, I fumbled again, and he rapped again. I stammered enzymes, in whatever order they came to my brain. Acetaldehyde dehydrogenase. Whap! Monoamine oxidase. Whap! Aldose reductase. Whap! Aldehyde dehydrogenase. Whap! Aldehyde reductase. Whap!

By the end of the case, the patient’s pheochromocytoma had been removed, my knuckles were bloodied, and my thoughts of being a surgeon had been whapped out of me.

Afterward, I asked the attending surgeon if that was normal. He nodded and walked away. He returned the next day, approaching me during a prostate removal operation, and told me to scrub out. I was to have lunch with an emeritus faculty member, who drove me off campus to his favorite restaurant and told me that he, too, had initially considered psychiatry.

“What changed?” I asked.

“I liked reading about psychiatry, but I preferred spending time with the surgeons.” Leaning across the table, he continued, “You might prefer spending time with the psychiatrists.”

Message received. My remaining dreams of being a surgeon fell away.

When meeting today’s medical students, I think about how the senior surgeon, the chief resident, and my student self all failed in that moment. The resident’s behavior was abusive, the faculty member enabled it, and the student’s dream was altered. We all carried the failure forward into the profession.

Much has been done to change medical education, but not enough. A female medical student recently described her own experience of medical training to me by saying, “It still feels like this environment of ‘My dad beat me, so I beat my kids.’”

Her comment reminded me again of “The Bear.” How many Sydneys and Marcuses are run off by Carmys, repeating behavior that was learned from their own elders? We want the Sydneys and Marcuses of the world to carry forward the craft of the Carmys without their unprocessed worries. We do not want the next generation to choose which dreams to follow because of their worst days. The stakes are high for all of us, because the cumulative dreams of medical students determine the kind of health care our society will provide.

Watching “The Bear” can help physicians figure out how to change medical training so we can pass along our craft without transmitting the dream-altering abuse, and create educational structures that allow future physicians to better serve their patients.

Abraham M. Nussbaum, M.D., is a psychiatrist, chief education officer for Denver Health, and the author of “Progress Notes: One Year in the Future of Medicine (Johns Hopkins University Press, June 2024).