[Session #1 – 22 September 2021]
Good morning. I trust you are all well. I have inserted below the reading/reflection assignment (i.e., ‘The Struggle’) for Session #1 of our ‘Integrity’ virtual symposium. Remember -- the subject for our virtual symposium is maintaining integrity (in the structural or engineering sense of ‘integrity’) in difficult circumstances, particularly when the consequences can be costly and even dangerous. I am sharing again the slide I created several years ago to visualize the complexity of sustaining/recovering clarity re our sense of self as we enter/exit our places of work as part of the staff who collectively deliver care to patients (often in the context of human subject research and/or human subject education/training).
As this slide suggests, I routinely return to these six questions for examining and refreshing personal and/or professional integrity – (1) Who/what am I? (2) Who/what do I trust? (3) What do I do? (4) For whom do I do what I do? (5) To what end/outcome do I do what I do? (6) Within what values do I do what I do? I use these six questions to recall and organize insights into one’s integrity – mine, a colleague, a friend, a neighbor, new acquaintance, et al. I once met twice monthly – 6:00-6:45am at a mutually convenient IHOP – for six years with a young physician in his first years of practice after residency, with each breakfast conversation about his professional experience framed by some combination of these six questions. I encourage you to use the six questions similarly as we make our way through this virtual symposium together.
Re the format -- I will send you every three weeks or so a brief reading (e.g., ‘The Struggle’) along with a few discussion/reflection prompts. You are encouraged to (1) spend as much time as you can allot becoming familiar with and pondering/engaging each reading plus the prompts and (2) send to your fellow participants at least one brief e-mail response to each assigned reading when possible (please use ‘Reply All’ to the e-mail message I send the group at the start of each session). I will manage these group e-mail responses for each session and I will respond individually if/when a participant requests confidentiality.
Please know that I am honored, challenged, and humbled by the privilege to facilitate this shared examination of our integrity. What I bring to the virtual symposium is firmly rooted in the orientation to surgical ethics that distinguishes the Center for Humanism and Ethics in Surgical Specialties (CHESS) located in WashU’s Department of Surgery.
I look forward to hearing from you. And again, welcome!
Doug
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The Struggle**
Douglas Brown, PhD
Consider the intentions and the struggles of a young surgeon in her first years of practice after residency. Let’s call her Stephanie. Stephanie is the youngest and newest member of a team of surgeons whose practice is administered by a for-profit management company. She joined this practice with the assurance she would be fully supported in her deeply-rooted resolve to care for her patients in the most beneficial and cost-effective way, with special attention to socio-economically disadvantaged patients. She quickly discovers that numerous competing interests and expectations – some professional, others personal – pressure her to shift her focus away from her patients and their interests.
Stephanie begins most days poised to be empathetic. She is prepared to give disproportionate attention to her more vulnerable patients. She is ready to open herself to her patients’ suffering to the point of risking burnout. She intends to be meaningfully present with her patients. She grips firmly her integrity. She gauges her capacity to tolerate the moral dissonance she experiences from value clashes with some of her patients. She seeks to grow professionally for patient benefit more than for personal security. She feels a nagging tension between her lifestyle interests and her accountability to her patients.
Stephanie would violate her integrity if she refused to look beyond each patient’s presenting clinical problem. She has already seen far too much. However, she accepts that she is not yet one of those rare surgeons who seem capable of saying “yes” to every deeply pained patient and entering into every broken story. Fatigue, accountability to her other patients, administrative obligations, family responsibilities, reimbursement pressures, personal interests apart from medicine, and a host of other considerations force her to limit many patients’ access to her time, her energy, her humane intentions. Instead, Stephanie triages her patients carefully in her mind to identify the encounters in which she will enter most deeply into the patient’s story, in which she will make and impose on others the sacrifices associated with being fully present with the patient.
Especially on her most exhausting days, Stephanie might glance enviously toward the many apparently flourishing surgeons for whom the medical environment is most fertile. For these surgeons, a patient encounter is a sale; the patient, a consumer. Some are entrepreneurs. Lifestyle incentives motivate them. Some are researchers. Innovation and publication motivate them. They subtly sift out difficult patients from their panel of patients. They stay sufficiently detached from patient suffering to avoid being burned out. They have learned to make patients think they are present and care. They turn professional advancements into marketing tools. They lead unreflective lives. They have an easy conscience. But Stephanie is not seriously tempted to join their number.
However, Stephanie is troubled by how often she ends the day wearily thinking of the next patient as one more demand; thinking of herself as a mechanic. She ends many days numb toward patients and tired of confronting the healthcare delivery system. She feels acutely the loss of important family experiences as she does her job. She often sees little evidence that she is making a difference in the lives of vulnerable patients. She finds herself becoming apathetic to patient suffering as the day’s paperwork drains her. She feels ambivalent toward patients for whom she has a dimming vision. She senses that her barely staying current with advancements in her specialty is posing subtle risks to patients. She is haunted by the look in her child’s eyes, a look that asks, “Mom, do you care more for your patients than you do for me?” She can sound defensive. She can look disheartened.
Our virtual symposium centers on the vulnerability of surgeons such as Stephanie and the many other surgeons who lack her deeply-rooted, well-grounded resolve to care for all patients – including the most difficult patients -- in a respectful, beneficial, fair, and cost-effective way. As their careers unfold, they too often yield – some with initial remorse – to incentives to practice surgery in ways that actually – if subtly – discourage them from being genuinely present with patients. They too often lose their initial qualms with hedging their fiduciary responsibilities to patients. They too often compromise . . . even surrender their integrity.
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** The ‘Stephanie’ narrative is my attempt to compress in a historical fiction format the insights into the struggle to maintain integrity healthcare professionals have revealed to and clarified for me during my four decades embedded among them as an anthropologist and an ethics educator. Accompanying the ‘Stephanie’ narrative, I have created a language matrix that differentiates four common professional identities found on a spectrum with “I could not care less” at one end and “I could not care more” at the other end plus a language matrix that tracks the dynamic degrading and refreshing cycles surgeons represented by ‘Stephanie’ who are resolved to maintain their integrity in challenging and at times threatening professional settings. The matrices below can each be read in two directions – (1) laterally to see the differentiated profiles and (2) vertically to see more deeply and comprehensively into any one of the differentiated profiles. The narrative and the matrices continue to be refined.
