Do physicians attempt to keep alive a humanizing practice of medicine that is neither highly valued nor seriously nourished by the medical education and academic or private practice environments? My experience as an imbedded ethicist inside the medical education and academic or private practice environments has left me with these impressions. A small but nonetheless deeply disturbing number of physicians practice medicine in a fraudulent manner that exploits and assaults patients (i.e., the physician profile in column one). A comparably small number of single-minded physicians are so wedded to medicine that they concentrate all their energy on caring deeply for every patient and challenging prophetically the systemic flaws that oppress patients (i.e., the physician profile in column four). Their single devotion to medicine, sadly, often exacts a damaging price from their personal health, from their support staff, from their spouses, from their children. Most physicians settle somewhere on the spectrum of what is sanctioned as ‘good performance’ in the medical education and academic or private practice environments (i.e., the physician profile in column two). They embrace incentives to practice medicine in a way that actually – if subtlety – discourages being genuinely present, humane, and fair with patients. Many physicians in this number choose so early to plant themselves safely within the medical education and academic or private practice environments’ more fertile regions that they have no qualms hedging respect and compassion for patients. Many other physicians in this number are despondent about the long-since faded intentions they professed so clearly in their personal statements for medical school and residency. Far fewer physicians end each day exhausted but still holding themselves accountable to care deeply for their patients, still finding their character most clearly revealed in how they treated their most difficult patients, still looking to exercise a strong social conscience in their practice of medicine (i.e., the physician profile in column three). They are resilient. But they are at risk – perhaps endangered -- because their professional ethic puts them in the barren soil of the medical education and academic or private practice environments.
Which of these four physician profiles best represents how you want to be remembered at the end of your career? When those who know you best -- your spouse, your child, your closest colleague, your longtime nurse, your special friend – ask themselves about your practice of medicine, where on this spectrum do their reflections on you as a physician settle?
A few weeks after Dr. Elkins’ untimely death, his wife Carolyn and I sat silently in his office here at Johns Hopkins. The office had not been disturbed since Tom’s death. After several minutes, Carolyn spoke quietly, “It feels like Tom will come rushing through the door any moment. How do we go on? What was it all about?”
I thought back to when Tom and I met in 1980. He had been reassigned to the naval hospital just north of Memphis to complete his commitment to the Navy. I was a novice graduate professor, teaching history and ethics courses. Tom wanted to take a few humanities courses as he transitioned into his career as a teaching physician. He had looked in the yellow pages for a university that offered night courses. I had just begun the first class meeting of my ‘Classics of Spirituality Literature’ course when I saw in my peripheral vision to the left a white blur. It was Tom in his Navy uniform. I soon discovered one of my most searching students, one of my most trusted friends.
Eighteen years later – after countless collaborations – I turned around and Tom was gone. No more rounds. No more clinics. No more surgeries. No more conferences. No more Africa trips. No more pats on the back. No more playful bantering.
Tom left behind a legacy of accomplishments that would be exceptional for a full three-score-and-ten life span. What indeed was it all about? Why did he work day after day to the point of exhaustion? Why did he spend so many hours in the anatomy lab doing research to improve procedures for pelvic surgeries? Why did he patiently educate the uninformed and confront the barriers in order to start model clinics for delivering gynecologic health care to women with mental disabilities? Why did he return again and again to Nigeria and Ghana, knowing yet another bout with malaria could not be avoided?
Sitting quietly in his Hopkins office, I reminded Carolyn that idealistic young men and women begin medical school confident they will be humane physicians. They must immediately adjust to being herded through a grinding eight years. Their every step is evaluated as they master basic medical information, become efficient in examining patients, and learn to do procedures. They absorb standards for identifying ‘good performance’ that have little to do with valuing patients as individuals. They finish residency still feeling the effects of chronic fatigue, but anxious to focus on their patients. Instead, they struggle for several years to find their own practice styles among new colleagues and under the oppressive fiscal scrutiny of their practice administrators. They receive few, if any, incentives to give of themselves . . . to care deeply . . . to be truly present with their patients . . . to concentrate on the disadvantaged . . . to be reflective. By their early 30s, they have acquired a trade. They have job security. But the dreams with which they began have all but faded away. They are practicing a kind of medicine they had not intended.
“Carolyn,” I said, “It was about reaching out to those young men and women. Some viewed Tom as an anachronism, a Don Quixote. I will remember Tom as a visionary within the medical education and academic practice environments, defending the idea(l) of being a humane physician who is truly present with patients and who exercises a resolute social conscience in the practice of medicine. He cared . . . really.”
If your eyes have been opened – as had Tom’s -- to what masquerades as professional integrity. If you have experienced – as had Tom -- compassion fatigue, caring fatigue. If you have found yourself – as did Tom -- wondering, “Do I care . . . really?” Then for you, ethics has essentially to do with two tasks – (1) finding firm moral ground on which to stand as a physician and (2) accepting the responsibility to invest in the nurturing relationships/experiences that enable you day after day to return refreshed and encouraged to your profession, not just to your work.
Which of these four physician profiles best represents how you want to be remembered at the end of your career? When those who know you best -- your spouse, your child, your closest colleague, your longtime nurse, your special friend – ask themselves about your practice of medicine, where on this spectrum do their reflections on you as a physician settle?
A few weeks after Dr. Elkins’ untimely death, his wife Carolyn and I sat silently in his office here at Johns Hopkins. The office had not been disturbed since Tom’s death. After several minutes, Carolyn spoke quietly, “It feels like Tom will come rushing through the door any moment. How do we go on? What was it all about?”
I thought back to when Tom and I met in 1980. He had been reassigned to the naval hospital just north of Memphis to complete his commitment to the Navy. I was a novice graduate professor, teaching history and ethics courses. Tom wanted to take a few humanities courses as he transitioned into his career as a teaching physician. He had looked in the yellow pages for a university that offered night courses. I had just begun the first class meeting of my ‘Classics of Spirituality Literature’ course when I saw in my peripheral vision to the left a white blur. It was Tom in his Navy uniform. I soon discovered one of my most searching students, one of my most trusted friends.
Eighteen years later – after countless collaborations – I turned around and Tom was gone. No more rounds. No more clinics. No more surgeries. No more conferences. No more Africa trips. No more pats on the back. No more playful bantering.
Tom left behind a legacy of accomplishments that would be exceptional for a full three-score-and-ten life span. What indeed was it all about? Why did he work day after day to the point of exhaustion? Why did he spend so many hours in the anatomy lab doing research to improve procedures for pelvic surgeries? Why did he patiently educate the uninformed and confront the barriers in order to start model clinics for delivering gynecologic health care to women with mental disabilities? Why did he return again and again to Nigeria and Ghana, knowing yet another bout with malaria could not be avoided?
Sitting quietly in his Hopkins office, I reminded Carolyn that idealistic young men and women begin medical school confident they will be humane physicians. They must immediately adjust to being herded through a grinding eight years. Their every step is evaluated as they master basic medical information, become efficient in examining patients, and learn to do procedures. They absorb standards for identifying ‘good performance’ that have little to do with valuing patients as individuals. They finish residency still feeling the effects of chronic fatigue, but anxious to focus on their patients. Instead, they struggle for several years to find their own practice styles among new colleagues and under the oppressive fiscal scrutiny of their practice administrators. They receive few, if any, incentives to give of themselves . . . to care deeply . . . to be truly present with their patients . . . to concentrate on the disadvantaged . . . to be reflective. By their early 30s, they have acquired a trade. They have job security. But the dreams with which they began have all but faded away. They are practicing a kind of medicine they had not intended.
“Carolyn,” I said, “It was about reaching out to those young men and women. Some viewed Tom as an anachronism, a Don Quixote. I will remember Tom as a visionary within the medical education and academic practice environments, defending the idea(l) of being a humane physician who is truly present with patients and who exercises a resolute social conscience in the practice of medicine. He cared . . . really.”
If your eyes have been opened – as had Tom’s -- to what masquerades as professional integrity. If you have experienced – as had Tom -- compassion fatigue, caring fatigue. If you have found yourself – as did Tom -- wondering, “Do I care . . . really?” Then for you, ethics has essentially to do with two tasks – (1) finding firm moral ground on which to stand as a physician and (2) accepting the responsibility to invest in the nurturing relationships/experiences that enable you day after day to return refreshed and encouraged to your profession, not just to your work.
