Greetings from St. Louis and WashU. It was great to visit with several of you during the recent ACS Clinical Congress in San Francisco. Forty-eight from our surgical ethics working group were able to attend the Tuesday evening dinner meeting. For ‘Surgical Ethics Education Resources’ communication #24, I am sharing with you an article I am pleased to have included in the Fall/November 2019 issue of Literature and Medicine. Each article in this Literature and Medicine issue demonstrates a way to the use Albert Camus' novel The Plague as a primary resource for medical humanities courses. The issue's guest editor specifically asked me to explain how the relationship/collaboration between the novel’s two main characters – Dr. Bernard Rieux and Jean Tarrou -- has framed my personal narrative and has been my centering professional paradigm since I transitioned in the mid-1980s from being a history professor to being an ethics educator and qualitative researcher embedded in medical school departments, teaching hospitals, and non-profit community health centers. This article is the first time I have placed in print a detailed account of being with my first wife (d. 1987) through her unremitting fourteen year illness as a victim of multiple sclerosis. If you have the margin at some point, I will welcome your feedback.
I have taken the liberty to insert below one section from the Literature and Medicine article to draw your attention to one way the article might be a surgical ethics education resource for you to use. The section inserted below opens with a reminder that the core meaning of ‘disillusioned’ is to be rescued from or relieved of an illusion – i.e., ‘dis’ + ‘illusioned’. For many years, I have routinely opened educational sessions by placing this definition on the screen/board and then asking the participants to identify the word being defined. The typical responses are ‘enlightened’ or ‘educated’ or ‘illuminated’ or . . . but rarely ‘disillusioned’. The point – ethics has to do with how we regroup on the other side of a disillusioning experience. The section inserted below then offers a series of poignant examples from conversations with medical students, residents, and practicing physicians/surgeons.
Doug
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[a section from the Literature and Medicine article]
Dr. Rieux and Tarrou prompt me to see into the complexities of being disillusioned that seem unavoidable for healthcare professionals who care deeply for and about those most immediately and most often at risk. To be disillusioned is to be rescued from illusion, to be moved closer to reality. To be disillusioned is also to suffer a devastating blow to motivation, purpose, courage, resiliency, inspiration. Well-intentioned learners continue to be drawn to medicine by the vision of caring deeply for patients, by the vision of making a difference in patients’ lives. At various points across the continuum of medical education and medical practice, they realize the vision that drew them to medicine is, far more often than not, an illusion. For many humanistic language soon seems hollow, soon becomes embarrassingly naive.
Listen to these representative medical students, residents, and practicing physicians as they speak candidly about having their illusions torn away and about their struggles each time to regroup. Note especially the images they use to make their disorienting experiences vivid.
A frustrated medical student soon finishing his first year disclosed as we sat together at a mixer near the end of the academic year: “We had the ‘keep your balance, don’t lose your relationships’ orientation talk from the dean on Day One. And an ethicist we never saw again reminded us the same day to ‘nurture your interior life.’ Day Two blew by all that. After the first round of tests, reality set in. Getting decent grades means 80-100 hours of study every week. What’s left for relationships? or for my ‘interior life’? The grades for my first set of tests reassured me. I can do this. But at what price? Where is the dean? Where is the ethicist? Obviously not near enough to us to speak with understanding and integrity. I feel betrayed.” He expected the dean and the ethicist to recycle their platitudes in a few days to the next class of new students and wondered if or how to warn them. What are the odds this medical student would complete his training resolved to be humane and concerned about injustices? I asked myself how a Tarrou would be present with this student as he silently carried this sense of betrayal through his medical school years.
A confused third-year medical student, considered by the pre-clinical faculty to be one of the top students in her class, admitted soon after her first clinical rotation as we chatted briefly before rounds: “I am excited about finally being in the clinical setting. I want to help patients. I want to contribute to the team. I understand I need to make my upper level look good. And yes, I want to impress the residents and attendings. But now I feel very uncertain. Residents and attendings broke bluntly into my case presentations. It’s demeaning to be told – ‘We don’t have time for a 3rd-year medical student history and physical’— and then to be ignored. The one thing I thought I knew how to do was a history and physical. I am afraid of failing, of appearing weak.” After my first few months with 3rd-year medical students in a teaching hospital, I understood. The aim eye of medical students who have crossed the threshold into the complexities of actual patient care has to be on developing a functional knowledge base and on acquiring basic technical skills. The fraction of attention they can spare for focusing on a patient’s care being humane, respectful, and fair is small and at odd hours. How would a Tarrou make the most of the slight and erratic openings to add something substantive to their professional growth within such tight limitations?
A shaken medical student near the beginning of his fourth year, in response to my questions about the way he was selecting elective rotations and assessing possible residency programs, paused and then rather embarrassingly acknowledged: “It’s all about balancing residency program status with personal convenience. I am in the rural-track program of my medical school because I began with the intent to practice in an underserved area. But my fellow rural-track students and I hardly ever talk about that goal when we discuss rotations and the residency programs we are considering.” This student’s medical school had designed its curriculum to maximize each year the number of students who were intent on caring for truly rural and underserved populations. This student and his fellow rural-track students were to be examples and leaders. Instead, they had lost their distinction. What is revealed about the medical education milieu when an institution so intentional still fails to nurture one potential Dr. Rieux after another?
A tearful fourth-year medical student, during her interview for the residency program I was managing, revealed: “I majored in English Literature. But when I sat down to write my personal statement for the residency application, I discovered I had lost the skills to think in narrative style or to write an essay.” Yes, having majored in English literature meant she had very high standards. However, by the transition to residency most medical students have been steered away from the basics for telling or writing a story – e.g., character formation, plots and sub-plots, vivid descriptions, intrigue/surprise, passion – toward sterilized case presentations that are efficient, bare, and predictable. How many can still hear a plague victim’s appeals as Dr. Rieux did?
A second-year resident, during a lunch conversation, admitted: “By the third year of medical school, I realized that being a physician is not what I had envisioned. Being with patients and making a difference in their lives 90% of the time would be great. Even 70%. But 40% or less? I feel stuck. What else can I do? It is hard to quit after having invested so many years. I am not in medicine for the money. There are much faster and easier ways to that goal. My college friends are making shit buckets full of money while I am sacrificing my 20s and amassing an enormous debt. I am frightened by the ways I have changed. Fatigue has darkened my mood and shaken my plans. My family and friends do not understand how tired I am. Will these changes reverse after residency?” She added that she no longer viewed those who withdrew from medical school as weak but as courageous. She advised me not to encourage my sophomore undergraduate daughter to choose pre-med. Then after lunch, she drew the curtain of silence and returned to work. She progressed through the remaining two residency years. Can a Tarrou help someone in such intense professional pain?
A young physician, three years out from residency, explained: “The audience in residency is your attending physician. You tend to adopt his/her approach. If you take your own approach, you risk getting into trouble. So you put personal responsibility on a back burner. Your career rides on the attending’s interpretation and your upper level’s interpretation of your performance. Residents – especially interns – implement the decisions of those above them. They must move quickly. They know their medical analyses will be quizzed. They have little time to think about anything else. Every year that such reflection is suppressed, the harder it is to recover. Many residents take the position – ‘When I get out, I won’t do it that way.’ The danger in taking a ‘later’ attitude is that you tend to become what you do. Many days slip quickly into a downward spiral. You fall behind due to patient volume and the inability to anticipate or control the complexity presented by patients. Getting the work done takes over. Addressing the chief complaint without falling further behind severely restricts attention to deeper issues in the patient’s story. This cycle eats away at the joy of what you are doing.” I met this young physician near the end of his first year after residency. In the first few weeks with his new practice, he began to feel pressed to catch up to his partners in generating revenue. His spouse was just as insistent that he contribute to long-delayed family interests. He and I met at 6:00am every other Wednesday for six years searching as I imagine a Dr. Rieux and a Tarrou would for firm footing re five core questions essential to his integrity – Who am I? What do I do? For whom do I do what I do? To what end do I do what I do? Within what values do I do what I do?
A physician in his late 30s, a couple of years past his decision to leave the practice of medicine, looked back as we shared coffee and another conversation: “I made course selections for requirements other than pre-med courses based on whether a course or instructor would make it easier to get into medical school. The humanities were downplayed . . . downgraded at my undergraduate school. Pre-med students were perceived and thought of themselves as the toughest among all the students in science programs. The sneering about the humanities was severe. I did not realize then that to let the mental habits characteristic of the humanities atrophy is to let a crucial part of the self die. Yet students, residents, academic physicians, and practicing physicians who place value on these traits run the serious risk of being perceived as not being fully committed to medicine. Medical school and then residency are meat grinders that spit you out on the other side. You are pushed through. There is little or no opportunity to pause and assess. There is hardly any occasion to ask, ‘Why am I doing this? Is this what I want to do? Is this what I ought to do?’ It is ironic that during the years when you need to be most reflective, you do not have the tools, the time, or the energy.” He loved science. His academic record was outstanding. His clinical knowledge was deep. His technical skills were excellent. His work ethic was exceptional. His father was an internist. These gifts were sufficient to get him through training and into practice, but minus the skill to consistently integrate his intent to be truly present and stable with his patients and his colleagues. Realizing he was teaching me more than I was aiding him as he confronted the disturbing evidence that he would never be centered as long as he remained in medicine, I began searching in The Plague for indications Tarrou was transformed by Dr. Rieux’s presence in his life.
A physician with fourteen years’ experience as the lead physician for a community health center in a poverty-burdened and underserved region of East Tennessee Appalachia reflected on being a physician as we sat on a quiet ridge overlooking the valley: “Medical school and residency are not educating experiences. You are not taught how to think. You do not engage ideas. You memorize information and learn to make differential diagnoses. There is little historical perspective. Medicine is not integrated into larger and related spheres of thought. Becoming a physician is analogous to a trade school experience. Little attention is given to what it means to be a professional.” This physician stands out within the intimate circle of physicians in whom I have seen a Dr. Rieux. He has permitted me to be near – as a Tarrou – for the past twenty-five years as his career transitioned into a faculty position with his residency program and as we have found a way to be clinical and ethics education resources for physicians, medical students, nurses, and public health NGOs in Palestine (the West Bank and Gaza). He knows that an eye-opening experience is often not a life-changing experience. Our special friendship is anchored by a shared judgment that seeing life from the perspective of the most at risk patients and their families is an incomparable and unparalleled value by which we must live.
A physician in her late-40s reflected: “I remember quite clearly my first day in medical school. The dean did not mince his words. ‘Medicine must be your husband, your wife, your children, your family, your life. If you can’t make this commitment, get out now.’ I fought to keep hold of the grand ideas that brought me into medicine. I fought against the dean’s angle on medicine. And twenty-five years later, I am disillusioned about my profession, burned out, cynical. The medical school, residency, and practice settings have worn me down.” This single exchange reminded me of a recent conversation with the spouse of the first physician in whom I saw a Dr. Rieux. He created opportunities for me to be with him (“in the arena with us as a Tarrou” he delighted to say) as he navigated his academic career in uro-gynecologic surgery from a junior faculty member to a division chief to a department chair, from introducing model clinics for the gynecologic care of disabled women to using a simple surgical procedure to rescue women in Ghana whose lives had been ruined by lingering fistulas after prolonged labor and delivery. Just months into his appointment as chief of gynecologic surgery at a renowned medical school, he suddenly died. He was 49 years old. A few weeks after his death, his spouse and I sat quietly in his still untouched office before beginning to pack. After several minutes, she turned to me and asked, “What was it all about?” I remember pausing and then reassuring her, “It was about building communities in which every member begins life with hope, lives life with joy, and ends life with dignity.”
I have filled scores of journals with such vignettes. Dr. Rieux and Tarrou in The Plague sharpen my efforts to hear with insight the numerous stories of regrouping after being disillusioned I am privileged to be near enough to hear. Common to each story is the fact that the three required languages in medical education and medical practice – i.e., clinical, legal, and economic – all default to impersonal encounters that diminish patients as individuals.
The environments for medical education and medical practice are most fertile for impersonal encounters. Listen to echoes from rounds, patient records, call room conversations, doctor’s lounge conversations, grand rounds, morbidity-mortality conferences, evaluation sessions, faculty meetings, medical staff meetings, depositions, productivity reviews, and so on.
An ethic firmly rooted in a humanizing 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 a 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.
Dr. Rieux welcomed Tarrou. They worked side by side. They relaxed together. They became friends. Dr. Rieux used and refreshed his language of respect, compassion, and fairness with Tarrou. Tarrou’s role – to listen . . . to suggest . . . to recall . . . to question . . . to encourage.