general interest

The Man in the Arena: What Theodore Roosevelt Can Teach Us About Medicine.

How can a speech given over one hundred years ago by the 26th President of the United States help current day doctors deal with the demands of their profession.

Photo by Smithsonian / Unsplash

Would you choose medicine again? It is a question that most doctors have asked themselves at some point in their careers. Medicine offers extraordinary opportunities to help others but it also brings considerable personal and professional costs. The responsibility, the constant uncertainty and the emotional demands are often seem difficult to reconcile with a fulfilling life.

We enter the profession with idealism and a desire to make a difference. Yet years of difficult decisions, mistakes, complaints and organisational pressures can gradually erode that enthusiasm. We work in a profession that can be immensely rewarding but also exacting in ways that are not fully recognised or understood.

Perhaps we need to remind ourselves why we entered the profession and what makes the struggle worthwhile—what it means to practise medicine and what we should expect of ourselves. How do we maintain our enthusiasm and sense of purpose in such an demanding environment?

More than a century ago, Theodore Roosevelt, the 26th President of the United States, delivered a speech that offers an interesting perspective on this dilemma. His words about courage, failure and the willingness to enter the arena have particular relevance to the medical profession.

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat. Theodore Roosevelt (1910)

The Man in the Arena

On 23 April 1910 Theodore Roosevelt delivered a speech at the Sorbonne, the University of Paris, entitled Citizenship in a Republic.¹ After eight years in office, Roosevelt had embarked on a major scientific expedition to East Africa, collecting specimens for the Smithsonian Institution. He was now travelling through Europe, where universities and public figures were eager to hear him speak. Although he remained a celebrated public figure, his future political direction was uncertain.

The address was nearly 9,000 words long. Roosevelt wanted to explore what citizenship demanded of ordinary people in a democracy. He argued that a republic could not depend solely on the wisdom of its leaders. Its long-term success rested on the character and conduct of its citizens, particularly those who enjoyed education, privilege and influence, and therefore had a responsibility to serve others.

At the heart of his argument was the belief that credit belongs not to the person who stands on the sidelines and criticises, but to the person who enters the arena and makes the attempt. Roosevelt understood that meaningful endeavour inevitably involves risk. Anyone who attempts something difficult will sometimes get things wrong. Leaders will make poor decisions, competitors will lose and those who create something will expose themselves to judgement. These are not necessarily signs of inadequacy. They are part of the price of participation.

The passage now popularly known as The Man in the Arena was only a small part of the original speech, but it has become one of the most enduring reflections on courage and human endeavour. It also inspired Brené Brown’s 2012 book, Daring Greatly.²

Roosevelt’s argument is not that effort guarantees success, that mistakes should be excused or that criticism should be ignored. Rather, he asks us to distinguish between the person who accepts the vulnerability of trying and the spectator who judges the attempt without sharing its risks.

He concludes—the person who fails while "daring greatly" has at least experienced the struggle. Those who remain outside the arena may avoid defeat, but they also forfeit the possibility of achievement, growth and self-improvement.

Medicine has a particular claim to this message. Roosevelt’s speech offers no specific prescription for dealing with the challenges of our profession, but it provides a valuable perspective on how we might approach our work with greater courage, resilience and, ultimately, satisfaction.

The Arena of Medicine

An "arena" is any situation involving meaningful endeavour, where our actions have consequences and we are open to judgement. As doctors, we know the arena in which we work, but describing its full complexity is frustratingly difficult.

Some aspects are readily recognised: time pressure, fatigue, staffing shortages and limited resources. Medical dramas have highlighted some of these challenges but there remains little appreciation of the true reality of a doctor’s working life.

Much of what makes medicine difficult is invisible. Perhaps the greatest example is the management of uncertainty. Every day, we make decisions with incomplete information. The complexity of this process is rarely apparent during a consultation. We are constantly assessing risk, weighing probabilities and making judgements. Sometimes we are right; sometimes we are wrong. Sometimes we make entirely reasonable decisions and the outcome is still poor or the patient is unhappy. The consequences can be significant. Medicine is not an exact science.

Consultations can be challenging. Communication difficulties, conflicting expectations and differences between patient and doctor agendas can make even relatively straightforward encounters demanding. There is a considerable emotional burden to the work. We can dwell on our decisions, question ourselves and carry the distress of difficult consultations into the rest of the day. Yet we must find a way to put these experiences aside and give the next patient our full attention.

Frontline doctors work under constant pressure to see more patients and improve patient flow. This pressure is not always communicated directly, but it is often felt through performance data, feedback and expectations around productivity.

Another largely invisible aspect of medicine is what has become known as repair work.³ This describes the additional, often unrecognised work undertaken by doctors and other healthcare staff to keep struggling systems functioning. It might involve finding a workaround during a crisis, covering for an absent colleague or simply giving someone the opportunity to talk through their difficulties. Much of this work is essential to keeping the system afloat, yet it is rarely recognised or adequately valued by managers. Repair work deserves much greater attention in its own right.

Urgent care in New Zealand has some particular challenges. The landscape of frontline medicine is changing, with many patients who might previously have attended an emergency department now presenting to urgent care. We see large numbers of undifferentiated patients with ambiguous symptoms, incomplete histories and evolving illnesses. Clinicians must rapidly decide whether to investigate and treat in the community or escalate to hospital admission. These decisions are often not clear cut. Long waiting times are common and can sometimes equal or exceed those in emergency departments. This creates a particularly demanding environment in which urgent-care doctors are highly vulnerable to complaints from patients and criticism from hospital colleagues who may not fully appreciate the circumstances in which decisions are made.

There are also what I would describe as sub-arenas within medicine. Different specialties have different demands, pressures and constraints. General Practice, for example, is quite different from Emergency Medicine, with its own particular workload and time pressures. Even within a specialty hierarchies can also create different arenas.

Consider the difference between an emergency medicine registrar and a consultant in New Zealand. Registrars often work a substantial proportion of their shifts in the evening and overnight, with the associated longterm fatigue. They have considerable training requirements, including regular workplace assessments and feedback that can be challenging. They may also have less professional influence and receive less recognition from other specialties. Consultants, by contrast, generally have more control over their working patterns, greater professional standing and fewer formal CME requirements. Although both groups undertake similar clinical work, they do so under quite different conditions.

Shift work creates further distinctions. A doctor working overnight is managing not only the clinical demands of the job but also the effects of fatigue and disrupted sleep. They are not operating in quite the same arena as a colleague working during the day. Workplace culture, available resources and personal circumstances create further differences.

Society rightly expects high standards from doctors. However, these expectations are rarely accompanied by an adequate understanding of the conditions in which we work. A deeper understanding of the medical arena will be beneficial to us all.

Effort

Roosevelt values effort— "the man...whose face is marred by dust and sweat and blood" over spectating. But if we believe that the person in the arena deserves credit simply for trying, we might conclude that effort alone is sufficient. It is not. Good intentions do not compensate for poor performance.

Effort relates to difficulty. Coping with difficulty leads to growth. The value of entering the arena lies not only in the effort itself, but in what we learn from the experience. Difficult encounters, mistakes and disappointments can become opportunities for personal development.

We should not aspire merely to survive the arena. We should aspire to emerge from it as better doctors and better citizens. There is dignity in the effort of participation—the attempt.

Courage

We need courage not only to enter the arena but also to remain in it. Courage in medicine is rarely dramatic. More often, it means doing what is necessary despite discomfort or uncertainty. It takes courage to make difficult decisions, reach an uncomfortable diagnosis, explain an uncertain prognosis, challenge a colleague, refer a patient to hospital or decide that someone can safely be managed in the community.

It is asking the question nobody else has asked, admitting uncertainty to a patient or seeking a second opinion. It means challenging unsafe practices respectfully but firmly, speaking up when staffing or organisational pressures compromise patient care, and recognising when we are tired, stretched or out of our depth and need help.

These decisions can carry costs. A referral may be criticised as unnecessary; a decision not to refer may be questioned if a patient deteriorates. Raising a safety concern may be inconvenient for managers or unpopular with colleagues.

Medicine requires the courage to accept that we will sometimes get things wrong. Our responsibility is to make the best decisions we can with the information available, remain open to learning and accept accountability for our actions.

It can be tempting to protect ourselves by avoiding difficult decisions or passing responsibility to others. But entering the arena means accepting that responsibility. The aim is not to be fearless or infallible—it is to develop the judgement to know when to act, when to seek help and when to recognise the limits of our expertise.

This is the courage of the doctor who, in Roosevelt’s words, is imperfect but "strives valiantly". We need more courage in medicine.

Vulnerability

In Daring Greatly, Brené Brown explores how fear of judgement can prevent us from growing and making connection. She distinguishes between guilt, which says, “I did something wrong”, and shame, which says, “There is something wrong with me.” Criticism can trigger shame when we interpret a mistake as evidence of personal inadequacy rather than an opportunity to improve. We become defensive, lose confidence or begin to conceal our uncertainty. Shame thrives on silence.

Brown makes the point that many people say that they "don't do vulnerability"—they confuse this with weakness. For a doctor however, there is no choice. The mere act of entering the arena is vulnerability. As Roosevelt reminds us, meaningful work involves exposing ourselves to the possibility of failure and judgement.

There are two paradoxes with vulnerability in medicine. Firstly we develop strength and courage by actually embracing vulnerability. Secondly, vulnerability is linked to greater self awareness, the willingness to admit uncertainty, seek help, speak up, acknowledge mistakes and speak honestly about difficult experiences. These are not signs of weakness but essential for patient safety.

Medical culture does not generally encourage vulnerability and many would probably say that it is a shame-prone culture; especially in hospital specialities. We are expected to be competent, confident and decisive. Admitting uncertainty or acknowledging a mistake can feel like an admission of professional weakness. The instinct is often to protect ourselves rather than expose our vulnerability.

Vulnerability is not about exposing ourselves indiscriminately. It is not over-sharing. In medicine, its practical application is less clear and will be dependent on trusted collegial relationships and empathic workplace cultures.

We cannot eliminate the fear of judgement but we can understand our own self worth and develop resilience to shame. We need more awareness and research into the concept of vulnerability in medicine.

Mistakes

One of the most important elements of Roosevelt’s argument is his acknowledgement that the person in the arena “errs” and “comes short” repeatedly. We must accept that mistakes are an inevitable part of clinical practice and that mastery of our profession is never complete.

Over the course of my career, I have worked with some outstanding doctors, but I have never met one who never makes a mistake. Even the most senior doctor will make mistakes. This is an uncomfortable truth for a profession that places such a high value on competence. We develop a professional identity around being capable and reliable. When something goes wrong we may question not only our decisions but our identity as doctors.

An error can become evidence, in our own minds, that we are not good enough. A complaint can undermine our confidence, and a difficult interaction can occupy our thoughts long after the consultation has ended.

When mistakes happen, we should reflect honestly and ask ourselves two questions: What can I learn from this, and what needs to change? These questions require honesty, not self-punishment. We must acknowledge genuine shortcomings without turning every imperfection into a judgement on our worth. There is an important distinction between learning from a mistake and allowing it to define us.

The doctor who can examine their practice without becoming defensive, and accept responsibility without descending into shame, is better placed to improve. The most useful response to failure is neither denial nor despair, but curiosity. Acknowledgement leads to strength.

Criticism

Medicine has a strong culture of evaluation. Feedback is essential for professional development and public safety. Roosevelt’s message is not an invitation to disregard criticism or an exemption from scrutiny. However, criticism should be fair and take account of the realities of the work being judged.

Sometimes criticism identifies genuine weaknesses in our practice. At other times, it reflects incomplete information, unrealistic expectations or a misunderstanding. A complaint can contain valuable lessons without every allegation being justified.

Unfortunately, criticism is not always constructive. Complaints can feel like personal attacks, particularly when our integrity or professionalism is questioned. Criticism between colleagues can be influenced by rivalry and personal agendas. Poorly delivered criticism can be deeply demoralising, especially when it ignores the circumstances in which decisions were made. Disproportionate criticism can undermine confidence and encourage defensive medicine and risks discouraging sound clinical judgement and independent decision-making.

We must also be cautious about hindsight bias especially when judging an outcome that could not have reasonably been predicted. Hindsight makes clues that were often ambiguous at the time appear obvious.

We need to distinguish between useful feedback, disproportionate criticism, unfair judgement and bullying. Three questions can help:

Is the criticism accurate? What does the evidence show, and what were the circumstances?
Can I learn something from it? Even unfair criticism may reveal an opportunity to improve.
What is outside my control? Other people’s expectations and reactions cannot always be managed.

This approach avoids two extremes: dismissing criticism because it is uncomfortable and accepting every accusation as proof of failure. We should listen, reflect and change what needs changing, then move forward. This requires both humility and resilience. If take this approach we elevate ourselves.

Every doctor is both a person in the arena and, at times, a spectator— we also judge the decisions of our colleagues. We should hold one another accountable, but with the fairness, empathy and understanding we would hope to receive ourselves. Before judging another doctor, we should remember that we may not fully understand the circumstances they faced.

Compassion

Medicine rightly teaches us to show empathy towards patients. Yet repeated criticism and emotional strain can make us defensive, cynical or detached. We may gradually begin to see patients as potential sources of complaints rather than people seeking help.

Emotional distance can protect us from hurt, but at the cost of the compassion that brought many of us into medicine in the first place. Roosevelt’s arena reminds us that meaningful work requires vulnerability. We cannot care deeply while expecting every decision to be appreciated or every outcome to be favourable.

Compassion does not mean accepting abuse or sacrificing our wellbeing. Boundaries and supportive working conditions matter. But we must learn to separate difficult encounters from the value of our work. Patients may be dissatisfied despite receiving reasonable care. Outcomes may be devastating despite our best efforts. We can acknowledge distress without automatically assuming we have failed. A difficult day does not erase the good we have done.

Although medicine is one of the caring professions, compassion is not always extended to colleagues or ourselves. Even with colleagues we have known for years, we may have little understanding of what they are experiencing in their personal lives. Incivility and a lack of empathy can be destructive to individuals and teams. Genuine compassion, by contrast, helps colleagues feel valued, supported and better able to do their work.

We also need to show greater compassion towards ourselves. We will never be perfect, and we will continue to make mistakes. We should remember though that we are doing worthwhile work. Every day, doctors bring knowledge, reason and humanity to situations that are often frightening, uncertain and difficult. In doing so, we contribute something valuable to the world.

We should not measure our worth solely by our clinical performance or the approval of others. We have chosen to enter the arena, to accept responsibility and to try to make a difference. That matters. Professional improvement will always be possible, but our worth as people does not depend on achieving perfection.

Respect

Doctors work in different specialties, environments and roles. General practitioners, emergency physicians, urgent care doctors, surgeons and intensivists face different demands, constraints and responsibilities. Even within a specialty, clinicians can encounter very different patients and working conditions.

We often see the decisions our colleagues make without fully appreciating the circumstances in which they made them. They may simply be confronting a difficult problem from a different perspective. Roosevelt encourages us to pause before judging. We need more mutual respect in medical culture. We are all working in the arena.

Three habits can help when assessing the work of colleagues:

Respect the person, even when challenging the decision. Professional disagreement should always be expressed with courtesy and dignity.
Seek to understand before criticising. Ask what the colleague knew, what they were trying to achieve and what constraints they faced.
Recognise our shared vulnerability. Every doctor can miss a diagnosis, make an imperfect decision or need help.

Stoicism

Roosevelt was influenced by Stoic philosophy. He valued courage, self-discipline, duty and resilience, reflecting the four cardinal Stoic virtues of wisdom, courage, justice and temperance. He was a reader of Stoic literature and reportedly took Marcus Aurelius’s Meditations and the works of Epictetus with him on his South American expedition to explore the River of Doubt.

Although Roosevelt does not offer specific Stoic advice in his speech, several Stoic themes run through it. Facing adversity, maintaining dignity, respecting others, developing character and placing virtue above external measures of success are all central to Stoic philosophy.

Epictetus taught us to distinguish between what we can control and what we cannot, directing our efforts towards our own judgements, choices and actions. Marcus Aurelius emphasised our duties to others and the importance of serving the common good without allowing adversity to compromise our character. He believed that we had a responsibility to participate in society rather than withdraw from its difficulties.

These ideas permeate Roosevelt’s speech. His emphasis is essentially about character, the responsibility of service, civic duty and participation in the face of uncertainty—all highly Stoic ideas.

One of the most valuable insights of Stoicism is that we should not expect to feel happy or feel good all the time. We will inevitably experience frustration, disappointment, anxiety and periods of unhappiness. However, living according to our values and practising virtue can give us something more enduring than momentary happiness: a deeper sense of purpose, fulfilment and inner contentment.

We cannot expect to enjoy every working day or find every experience rewarding. But we can still take satisfaction in practising our profession with wisdom, courage, compassion and integrity.

Conclusion

A better understanding of the medical arena could foster greater mutual respect and compassion between colleagues. This alone would be an important step towards a healthier professional culture.

The problems of burnout and bullying in medicine tell us that things need to change. We need doctors who are happier, more fulfilled and able to sustain their commitment to the profession. As our careers progress, it is easy to lose sight of the fact that our ‘great devotions’ and ‘worthy cause’ represent a powerful force for good in the world. Roosevelt reminds us of the value of our contribution to society.

Doctors have an exceptionally demanding job, yet many of the difficulties they face remain poorly understood. There is a deeper message in Roosevelt’s speech. If we want doctors to remain in the arena, society, the public and the medical establishment must develop a greater appreciation of the realities of their working lives. We cannot expect people to keep giving their best without recognising the demands placed upon them.

We cannot protect ourselves from every disappointment, criticism or difficult experience. Nor should we retreat from the challenges that make medicine worthwhile. But we can develop the courage, resilience and wisdom to meet them. We cannot control everything that happens to us, but we can strengthen how we respond.