This post is in response to the following questions: If there is one thing you would like to see change in your faith or ethical tradition over the next ten years, what would it be? What role would you want to play?
Medical science is my faith tradition. Of all talk of medicine losing its soul, there is a false assumption that science itself once included this soul. Indeed, religious thought strongly shaped the work of physicians centuries ago. However, the emergence of the doctrine of medical science does not acknowledge such virtue. The modern precepts of medical science are founded on a biological model of disease, and more recently, a more expansive bio-psycho-social model. Even within this expanded model, the criterion of knowledge remains the same: graded from randomized control study (RCT) as the pinnacle of knowledge, to anecdotal at the bottom. Perhaps this is a reason behind the resurgence of medical humanism, it is partitioning the very indication of what medical science leaves out.
Now, in ten years time I would like medicine – and medical science – to step out of this approach. I would like medicine to take seriously the concept of sense of purpose. By serious, I do not mean that we ought to do randomized control studies on physicians with the goal of establishing a checklist for how to be empathic. Nor by serious do I mean as social scientists, that we ought to do semi-structured interviews for thematic content. By serious I mean engage in honest dialogue about our role and influence in the daily lives of our patients. You may say medicine does this already. We hold support groups and have well attended lectures on the patient-physician interaction. Yet such interventions are framed as exactly this – interventions, the problem being isolated gaps in knowledge. The problem is not in the gaps, but in the tradition. Where a tradition does not encourage or ritualize self-reflection, these gaps will persist interminably.
As with any faith tradition, medical science is no stranger to ritual. The most widely discussed ritual is the initiation passage of dissecting a cadaver, for what I believe are two reason; first, the sheer gruesomeness of the task and second, its establishment of the physician as distant from living flesh. Many rituals in medicine are vestigial and benign; listening for bowel sounds in a healthy patient, or meticulously documenting normalcy, both practices that have little clinical utility. Others are persistent and dangerous – lauding sleeplessness as virtue, or justifying patient jokes as healthy coping. In my seven months as a doctor, the most surprising ritual is characterized by its absence – rich discussion of why we do the work we do. I have two hypotheses for this. Either, we are driven to silence by tradition, or we are afraid. We have been inured by lectures on humanism to believe that everyone shares the same values for the same reasons. This is not true. My colleagues have provided health care in war-torn areas abroad, on the Mexican border, and have been moved by personal family illness to pursue medicine. These stories slowly trickle out when pressed, or after sleepless nights, though ironically, rarely in the context of providing medical care. Instead, we live by aphorisms, like “the patient always comes first,” but rarely reflect on the boundaries of such conditions. Does the patient come before fatigue? Family? Emotional exasperation? Does the severity of the disease matter?
To get to the heart of one’s sense of purpose involves posing non-linear questions, and discussing real, albeit slippery concepts: creativity, exuberance, zest, or becoming. Perhaps we would do well to start thinking like anthropologists. For the anthropologist Gilles Deleuze, clinical terms do not capture the human experience; he prefers to investigate individual desires in their subjective experience of “becoming.” In the words of Biehl, “ People’s everyday struggles and interpersonal dynamics exceed experimental and statistical approaches and demand in-depth listening and long-term engagements.” (Deleuze and the Anthropology of Becoming) I want to find out what “becoming” means to medical students, residents, and young doctors. And this takes time. Incidentally, the subject of sense of purpose is rich with potential for research – what are the relationships between creativity and success? How does one’s subjective sense of purpose match with an outside observer’s? But research alone will not transform a tradition. This is a long-term enterprise, for to recreate tradition we must boldly create new rituals.
These new rituals may include such ideas as reflective rounds, expanding Schwartz Center rounds, and character-centered evaluations, among others. First, there are initiatives in many medical schools to pilot reflective rounds, where after presenting the medical case, the care-giving team engages in dialogue about what came up for them personally, spiritually, or ethically. This type of rounding is unique in that it allows more than space to reflect, but the wisdom, strength, and character of caregivers to come out, in a way impossible within the existing clinical paradigm. Perhaps a medical student has cared for a dying relative and can offer a new perspective on a palliative surgical patient; or a surgery attending may offer how seeing so many preventive accidents helped inspire community work. Some of these precepts are codified within Schwartz rounds, which are a series of seminars designed to create dialogue regarding issues of humanism in medicine. Most recently at Boston Medical Center, an auditorium was packed together to hear a friend of a patient transporter talk about coping in the setting of the loss of his colleague. Finally, if we are intent on promoting values of humanism, character, and reflective capacity, we must invest in given residents and students knowledge of what this looks like. A character-centered approach to evaluation would include not only metrics for clinical reasoning, but also metrics for determination, curiosity, and reflective practice. The goal would not be evaluative insomuch as a springboard for conversation of why we do the work we do, and what inspires us to approach it with more passion and humanism. Maybe then we will begin to scratch the surface of our individual and collective sense of purpose.