‘Encounter’ is one of those everyday words in medicine. To encounter (Latin, in + contra) is to come upon another face to face, often unexpectedly. To encounter is to meet another suddenly, often violently. Each day is a series of encounters – turning hallway corners, crossing lanes, reaching for an object, getting in line, looking up from a table, chasing a prize, competing for a position, . . . . Encounters make concrete and visible the set of values, the sense of purpose, out of which we each decide what ought to be done.
Medical school is no exception. Residency is no exception. Academic medicine is no exception. Private practice is no exception.
The most efficient schema I have found in the history of ideas for framing what is at stake in every encounter is the ‘I-It’ and ‘I-Thou’ schema put forward by the highly regarded philosopher, Martin Buber (1878-1965). Born in Vienna and raised by his grandparents, Buber studied philosophy and the history of art at the Universities of Vienna, Berlin, Leipzig, and Zurich. Buber’s classic I and Thou was published in 1923, the year he accepted the chair of Jewish History of Religion and Ethics at Frankfurt University. Buber lost that post soon after Hitler came to power in 1933. By 1938 he had been completely silenced by the Nazis and had reluctantly immigrated to Jerusalem where he accepted the position of Professor of Social Philosophy at Hebrew University. He worked tirelessly to life’s end for a peaceful solution to Jewish-Palestinian relations. Reduced to a pregnant couplet, Buber’s core proposition was:
Medical school is no exception. Residency is no exception. Academic medicine is no exception. Private practice is no exception.
The most efficient schema I have found in the history of ideas for framing what is at stake in every encounter is the ‘I-It’ and ‘I-Thou’ schema put forward by the highly regarded philosopher, Martin Buber (1878-1965). Born in Vienna and raised by his grandparents, Buber studied philosophy and the history of art at the Universities of Vienna, Berlin, Leipzig, and Zurich. Buber’s classic I and Thou was published in 1923, the year he accepted the chair of Jewish History of Religion and Ethics at Frankfurt University. Buber lost that post soon after Hitler came to power in 1933. By 1938 he had been completely silenced by the Nazis and had reluctantly immigrated to Jerusalem where he accepted the position of Professor of Social Philosophy at Hebrew University. He worked tirelessly to life’s end for a peaceful solution to Jewish-Palestinian relations. Reduced to a pregnant couplet, Buber’s core proposition was:
“I-thou” can only be uttered with the whole of our being;
“I-it” can never be uttered with the whole of our being.
How might Buber’s proposition be transposed for reflection on being a physician? I think it would be:
“I-thou” is only defining for physicians who are centered by a grand humanizing idea;
“I-it” is never defining for physicians who are centered by a grand humanizing idea.
To treat someone as a ‘thou’ is to be artistic, subjective, freeing, reciprocal, gentle, engaged, holistic, attentive, patient, modest, trusting, graceful, reconciling, humanizing. In short, to be treated as a ‘thou’ is to be respected. To treat someone as an ‘it’ is to be scientific, objective, detached. Or to treat someone as an ‘it’ is to be rough, indifferent, curt, suspicious, selfish, alienating, dehumanizing.
Therein lies the complexity of patient encounters, the complexity of the artful practice of modern medicine. The values and decisions represented by ‘it’ behavior and ‘thou’ behavior can overlap. To be treated by a physician as an ‘it’ is not necessarily damaging. To illustrate: excellent medical care is scientific, evidence-based. The physician objectifies the patient with statistical associations or by concentrating on damaged/diseased body parts. Differential diagnoses reflect plausible cause and effect explanations. The physician necessarily focuses on the patient’s immediate problem more than on the patient’s larger story. The physician must be sufficiently detached to achieve aequanimitas or balance. (A similar analysis can be made with the patient as ‘I’ and the physician as either ‘it’ or ‘thou’.)
However, at some point, ‘I-it’ encounters and ‘I-thou’ encounters become mutually exclusive. At that threshold, only by keeping the ‘aim eye’ fixed on patients as individuals worthy of respect, compassion, and fairness can a physician avoid the indifference that degrades patient encounters into self-serving alienation . . . the indifference that leaves patients bruised, manipulated, exploited, dehumanized.
Every story of being disillusioned I have heard over the past 20+ years has had variables specific to the medical student, the resident, the academic physician, the practicing physician. Common to each story has been the fact that the three required languages in medical education and medical practice – i.e., clinical, legal, and economic – all default to ‘I-it’ encounters that diminish patients as individuals.
As this diagram’s shading from lush green to barren yellowish-brown suggests, the environments for medical education and academic or private practice are most fertile for ‘I-it’ encounters. Listen to echoes from rounds, dictations, call room conversations, doctor’s lounge conversations, grand rounds, morbidity-mortality conferences, evaluation sessions, faculty meetings, medical staff meetings, discussions about ranking residency candidates, depositions, productivity reviews, . . . .
An ethic firmly rooted in an ‘I-thou’ approach to patient encounters entails a fourth language -- the language of respect, compassion, and fairness – a fourth language that is fundamentally distinguishable from clinical language, from legal language, from economic language. Fluency in the language of respect, compassion, and fairness is not required to successfully complete medical school, to pass post-graduate boards, to be rewarded by practice management, to secure hospital privileges, to pass recertification examinations, to be promoted, to be elected to national positions of leadership, to be on the hospital ethics committee, . . . . Fluency in the language of respect, compassion, and fairness is, however, essential for sustaining the experience of being a humane physician who cares deeply about patients – especially the most difficult patients -- and who brings a resolute social conscience to the practice of medicine.