A Survival Guide for a Medical Career: Must We Swim With Sharks?

A Silent Crisis in Medicine

Medicine is seen as a meeting place for idealistic people committed to helping humanity, yet serious structural problems lie behind the scenes. Chief among them are toxic workplaces, a culture of bullying, and systemic indifference. Particularly evident during residency and specialist training, this toxic environment can leave many doctors burned out and sometimes lead to tragic outcomes. An intriguing text depicting this reality through a striking metaphor has become legendary in the medical community.

A Metaphor From the 19th Century to 2025 — Swimming With Sharks

Medicine is full of idealistic aspiring doctors who want to make a difference in people's lives. Yet the journey itself can be demanding and even exhausting. Remarkably, a text supposedly written almost two centuries ago still captures this reality today.

Allegedly written in the early 19th century by a mysterious French author using the name “Voltaire Cousteau,” “How to Swim with Sharks: A Primer,” an introductory survival guide ostensibly addressed sponge divers. Reading between the lines, however, reveals a subtle satire about dealing with toxic people.

Although the text's true origins remain uncertain, its presentation as a dinner speech in 1974 by Richard Johns, founder of the biomedical engineering department at Johns Hopkins University, helped it circulate in academic circles. Some sources even identify Johns as its actual author. The text may therefore be a genuine document from the early 1800s or a skillful fiction reflecting the spirit of that period.

Today, the metaphor circulates as a kind of “cultural guide,” particularly in medical schools. Students at many American medical schools encounter it early in their education. Trying to swim in an ocean full of sharks, in other words surviving in a toxic, aggressive system lacking empathy, becomes a reality embedded in young doctors' minds.

How relevant is this metaphor to medicine today? More fundamentally, why must we still swim with sharks?

The Anatomy of a Metaphor

The central metaphor is clear: “sharks” represent senior doctors, while “swimmers” are residents and young physicians. Even the opening sentence captures the situation:

“No one wants to swim with sharks. It is neither a recognized sport nor an enjoyable or exciting experience.”

The text opens with these words and offers an ironic guide to dealing with toxic people. It is known to be distributed to new students at UPenn's Perelman School of Medicine, one of the most prestigious medical schools in the United States.

Cultural Trauma: Is Toxicity a Teaching Tool in Medicine?

This metaphor may be destructive rather than empowering. During residency and specialist training, the emphasis on “resilience” often serves to maintain an existing toxic system rather than foster trainees' development. Pressure to toughen up eventually permeates professional life because we learn to deny vulnerability, rather than simply not show it. Sadly, the consequences can be severe.

Throughout my career, I have watched many young doctors withdraw silently or suffer psychological collapse because of this culture. Sometimes the consequences are tragic. Nobody wants to “swim with sharks,” yet we believe there is no other option in medicine's ocean.

The Dangerous Side of “You Must Be Tough”

When I first entered the profession, the first rule I encountered was “develop a thick skin.” Criticism, pressure, and sometimes even insults were treated as almost natural. Over time, I realized this was acceptance rather than a warning: “This is how things work here; you must change.”

But tolerating toxic behavior does not eliminate it. It allows the system to remain unchanged. Criticism is often met with responses such as “you're exaggerating,” “you're too sensitive,” or “stop playing the victim.”

Toxic Behavior, a Culture of Silence, and Microaggressions

According to the United States Centers for Disease Control and Prevention (CDC), reports of workplace harassment among healthcare workers have doubled since 2018. Harassment ranges from verbal attacks to overt bullying. The problem deepened further after the pandemic.

Sometimes this takes the form of microaggressions. A nurse, technician, or colleague may make your work harder, directing their frustration with the system toward you. Much of this behavior is not overt, but it is felt. Over time, its accumulated effects harm people rather than institutions.

“When resources dwindle and stress rises, people not only stop helping each other but sometimes actively try to make things harder.”

Lateral Incivility: A New Form of Bullying

One term used for this is “lateral incivility.” Unlike overt bullying, it usually takes the form of quiet, passive-aggressive behavior between colleagues. Examples include a nurse slowing tasks to make a doctor's life harder or a surgeon directing operating-room stress toward support staff.

Do Not Bleed: Emotional Health and Self-Awareness

One striking sentence in the text reads:

“If you are wounded, you must never bleed. The smell of blood attracts sharks to you.”

This metaphor emphasizes the importance of not showing emotional weakness. Yet this is not a healthy solution: suppressed emotions eventually return as anger, burnout, and depression.

Doctors are generally trained to care for patients but not to monitor their own emotional processes. This can lead to a serious long-term mental health crisis.

Where Should Change Begin?

Individuals alone cannot change an institution's culture. Leaders must take a clear, decisive stance. A zero-toxicity policy must be put into practice, rather than merely stated.

When change does not come from above, however, we must start from below. How we arrive at work each day, treat colleagues, or simply ask “Are you okay?” when someone feels unwell can break the chain.

If leaders do not stand up for their employees, burnout and profound disappointment soon follow.

Conclusion: Must We Swim With Sharks?

As compelling as Voltaire Cousteau's metaphor is, still having to “swim with sharks” in 2025 shows that the system has not changed. Real transformation requires institutional courage as well as individual resilience.

During this process, however, every healthcare worker should ask themselves: “How did I come to work today? Am I respectful toward others? When someone treats me badly, do I in turn treat others badly?”

Ultimately, the only thing we can control is our own attitude. Perhaps these small changes will herald larger waves.