On Practicing Medicine and Learning Virtue
Certain moments from one’s clinical training are unforgettable. A single story can capture a great deal of the absurd tragedy and pathos of life in a hospital or clinic: I will never forget the first time I heard a colleague say, “If we had only done this six hours ago, he might have survived…”, the first time I caught someone else’s error and saved a life, and the first time one of my own patients committed suicide. There’s one story that really sticks with me—though not a particularly dramatic moment at the time, upon reflection I think it reveals a great deal about the forces that corrupt clinicians’ souls.
It was in the middle of surgery rounds on a clinical team that was hell for everyone involved: patients, clinicians, families, and innocent bystanders. Bread-and-butter surgeries like inflamed appendices or gall bladders were covered by a different surgical team, so our team got everything else. Mostly, this was a rotating cast of patients harboring bacteria resistant to every antibiotic in the formulary, suffering with perpetually open abdominal wounds covered by vacuum devices, and moving back and forth between the hospital and its associated rehab facilities. Many of them had initially suffered their loss of integumentary integrity through trauma and, drawing from West Baltimore, most were poor. The residents were overwhelmed and exhausted.
Most of the attending physicians on this team were trauma surgeons, presumably because they were very skilled. Very few surgeons actually enjoyed operating on the same chronic abdominal wounds over and over again, and it was impossible for them to hide their distaste for the service. The workload, the secondary trauma, and the apparent futility of much of the work weighed on all of us, but it must have been all the more difficult for the ones whose names were recorded on every chart. One day, during table rounds, one of the attendings made a comment:
“If the nurse hasn’t given that drug by now, I’m going to jump off the helipad.”
Macabre humor and exasperation are par for the course on busy hospital services, but this comment was almost exclusively the latter, framed in an extraordinarily dark manner. He obviously didn’t mean it (most people who casually declare their intention to jump from a high place to a roomful of people don’t). From what I recall, the timing of the medication in question was an important, but not crucial, aspect of this patient’s care.
Here was half the content of “the hidden curriculum” in one statement: The extreme frustration at our patients’ conditions, but the futility of our efforts to help. The channeling of said frustration into hostility towards others—and one’s own self. The intensification of minor tasks into life-and-death statements. The incredible edifice of advanced hospital medicine—the helipad—turned to purposes against healing.
The other half of the hidden curriculum I learned in my clinical training was more subtle, but also more at odds with the code of ethics I have come to embrace. It was said that one of the Maternal-Fetal Medicine professors at our university used to start his Labor & Delivery shifts by writing “THE FETUS IS YOUR ENEMY” at the top of the whiteboard in their workspace. Five words containing a universe of implications. After a few weeks in any rotation, however, it was hard not to feel like patients and the family environments they came from were enemies. In the end, it felt like a lesson in how to hate the poor in order to survive.
This feeling of hostility was reinforced in a number of different ways. The workload itself and the things to do for patients felt overwhelming on most days; the idea of caring for another human being felt more like drudgery than the privilege that we had talked about in our medical school admission essays. Calling the mixture of paper charts and computer systems across most hospitals “Byzantine” feels unfair to the actual Byzantines, who at least tried to make their works beautiful. Patients who continued to suffer despite our best efforts tended to regard us as incompetent. The poorest and most afflicted patients were the ones who had the most intractable issues; they were also the least likely to be helped by any encounter with the medical system.
After all, the system in question was not really designed to fix problems caused by trauma, abuse, broken families, poverty, or injustice. It was designed to fix other, simpler, problems while still making money off of those it could not fix. Similarly, the educational system we clinicians were trained in was not designed to make us compassionate, kind, patient, or loving—much less those who might stand in solidarity with the poor. It was designed to impart the knowledge and skills that allow us to become professionals. And when I got to participate in activities (such as home visits or multidisciplinary team sessions) that were designed to help our patients in ways outside of the typical medical context, I saw that these practices were only possible financially in a specifically educational context where ends were being met with resident training funds through Medicare. The boundaries of the system were reinforced. These excursions, which should have been normal and common in any system which aspired to care for health, were the exception that proves the rule.
I can also recall times in my clinical medicine courses (spread out across the preclinical years) when professors talked about values and choices in a way that always felt strange to me. These were special courses, and since we weren’t tested on the material they were poorly attended and largely considered less relevant. I realize now that these doctors were trying to talk about the virtues and character that one must embody in order to be a good doctor, but they were trying to do so with a number of limitations. Chief among these were the lack of any real organizing principles for thinking about character or virtue, an environment that had to be generically non-religious in the values it espoused, and the fact that they could not take too much time or energy away from the more important tasks of the university (such as acquiring research grants or preparing students to get good scores on their national exams). Thus, their attempts were little more than flapping their wings while the whole system was halfway to the ground after leaping off the helipad.
I wish that I could say that the mission hospital in a foreign country where I practice now is free of the hidden curriculum and its pedagogy of hostility toward our patients, our colleagues, and ourselves, but the same problems lurk here, too. The main difference is that here I have both the freedom and the responsibility to instruct my students in the virtues of being a good physician. I get to tell them that this is my responsibility and I get to tell them that it is their responsibility to the students below them, both now and in the future. I am also incredibly grateful that I had several teachers, most of them outside of the university, who were able to help me learn the virtues of a good physician so that I could have any hope of passing them along. We can acknowledge the despair and evil that batters us for what they are and fight together as a spiritual community.
The current fad of embracing social justice in medical education is, I suppose, an improvement on relegating such matters to a single lecture nobody really attends. I fear, however, that without an honest conversation about how critical moral formation is to the life of a medical provider, there will be far more psychological violence unleashed on our patients and ourselves. It is impossible, I have learned, to be a person who truly works for the good of others unless one’s own heart has found a way to accompany those who are suffering through the sorrow and pain that all of the injustices of life deal out.
Matthew Loftus teaches and practices Family Medicine in Baltimore and East Africa. You can learn more about his writing and his family's work at http://MatthewAndMaggie.org. He invites you to follow him on Twitter.