Mending the Healers

I started medical school in 2013. That same year, David Bornstein reported in the New York Times that 84 percent of doctors thought that medicine was in decline and more than half would not recommend medicine as a career for their children. My own father, a family physician, urged me not to follow in his footsteps. I’m now a family physician myself with sons of my own, and I wonder what I will tell them.

Medicine is extraordinarily difficult to enter, yet more and more of today’s new physicians seem ready to exit. “Burnout” is the leading diagnosis — discussed ad nauseam everywhere from JAMA to BuzzFeed. This phenomenon is characterized by emotional fatigue, depersonalization, poor performance, low self-esteem, “moral injury” (originally a description of soldiers’ experience of war), and a reduced sense of personal accomplishment. A wave-making 2015 study from the Mayo Clinic suggested that 54 percent of physicians experienced at least one burnout symptom. By comparison, the burnout rate among the U.S. nonmedical population has remained relatively stable around 30 percent. Doctors are at a higher risk for burnout even after adjusting for factors like work hours.

Recently, the doctors summoned to fight Covid-19 have been further traumatized. “I spent years training to help people, but I have never felt so helpless in my life,” emergency physician Marc Ayoub told the Washington Post. In addition to the many failures that put frontline workers in untenable positions, there is the sense that nothing in their background had prepared them for the overwhelming questions the pandemic presents.

But something about the nature of medical work was broken well before the pandemic hit. The possible contributing factors are myriad: the morass of the EMR (the “electronic medical record”), the truly shocking weight of medical student loan debt, poor work–life integration, health care bureaucracy, and the changing face of patient expectations and the profession as a whole. Today’s physicians, particularly those like myself in primary care, are reimagined as “providers” who mainly exist to make health-related goods and services available to consumers. The language of “consecration,” used until 2017 in the physicians’ oath, is unnecessary.

As a critical mass of frustrated physicians gathers at the sickbed of their own profession, ideas for healing abound. There is a renewed focus on professionalism and much talk of “culture change.” Medical thought leaders already speak in terms such as “wellness,” “resiliency,” “empathy,” “mindfulness,” “humanism.” Weary clinicians have created meetings like “Schwartz Rounds,” in which doctors can share grief together over their dying patients (and perhaps their dying profession) in regularly scheduled rotations. Likewise, small gatherings like COMPASS (“Colleagues Meeting to Promote and Sustain Satisfaction”) and other seemingly endless iterations of “Meaning in Medicine” groups for physicians and trainees alike have proliferated. All are asking some version of, What is it that we’re doing here in medicine again? We’re even looking to puppies for help.

It can all feel overwhelming — like being a patient surrounded by different specialists, each one confident in his or her own assessments and plans, all while lying disoriented in bed wondering what the hell is going on and what the prognosis is.

As a new resident physician, I want to turn again to think about how students become doctors. It seems to me that the dissatisfaction of today’s physicians (and the patients we treat) has less to do with changing expectations, the burnout phenomenon, or not enough vacation time, and more to do with a closing of the medical mind.

In my first semester of medical school, I entered the anatomy lab. There, my fellow medical students and I treated the cadaver (recognized in medical training as “the first patient”) with an almost sacred respect. There was a ritual. We opened the hooded doors of each lab table like tombs and carefully pulled back covering fabrics like veils. When we set down our scalpels for the day, we sprinkled the cadavers with diluted embalming fluid in a process that resembled anointing. Those first days were marked by a combination of reverence, fear, and wonder.

This rite of passage is often crowned by a service honoring the cadavers and their families, sometimes held in a place of worship, where medical students reflect on the profound privilege and responsibility of the anatomy table, offering thanks to the community for trusting them with such a task. They describe their first work and their first patients with the language of gratitude and gifts, in steepled buildings that affirm the reality that there is much more going on in the anatomy labs of medical schools than mere dissection.

But just as this reverence fades into familiarity and even irreverence (nicknaming cadavers “A Wrinkle in Time,” tossing “scraps” of tissue in the trash, propping up bodily appendages in questionable positions), so is the slow, attentive paradigm of the anatomy lab supplanted by the habits of modern medical-school study.

The nudging shoulders of colleagues and friends — with hands physically together on the first patient — are replaced by the disembodied distance learning of the digital: learning platforms, databases, and question banks like Pathoma, OnlineMedEd, SketchyMicro, UWorld, and UpToDate. Today’s medical students listen to their lectures with earbuds in and headphones on, anywhere but in the classroom, accelerated at double speed on isolated computer screens, free from the distractions of teachers, classmates, or patients. The coronavirus pandemic has only exacerbated this, as medical schools have been forced to switch over fully to virtual study.

By their third year, medical students transition to clinical learning on the hospital wards, where burnout begins to undermine their best vocational intentions. There they also are exposed to the so-called “hidden curriculum,” in which the explicit, formal teachings of compassion and humanism exalted in ethics lectures are subverted by the “real-world” practices of cynicism, misanthropy, and CYA (“cover your ass”). Behind the scenes, medical students are “pimped” — a pitiless caricature of Socratic teaching in which they are publicly quizzed by attending physicians and upper-level residents until they fail.

Well aware of these difficulties — wordlessly apparent on the face of the average clinician — supervisors urge their students to commit to vague notions of “empathy” and “wellness” if they are to survive. At the same time, “respect for autonomy” is quietly perpetuated as the foremost principle of medical ethics, subtly suggesting an independent form of existence that all human beings should strive for, medical students included. How autonomy relates to patients who are vulnerable and marked by dependency is not clearly explained. Other such odd contradictions abound. The discourse emphasizes “social determinants of health” and “support systems,” but med students hardly ever see their own friends.

Wonder is replaced with worry. Medical students describe themselves as “drowning,” “just trying to stay afloat,” “forgetting how to be human,” or even say “I’m dying.” They may be joking, but not entirely. The irony is almost too obvious. As medical students study humans they seem to lose something of their own humanity. As they study healing they grow unhealthy. As they learn about life they describe something like death.

Medical students know that, practically speaking, it is only high performance on board exams that will guarantee them success: a position in a residency and a specialty they desire. Doing well on the USMLE (United States Medical Licensing Examination) exams — designated in the lingo as “Step 1” and “Step 2” — becomes the medical student’s primary purpose. As physician Brenda Sirovich put it in the Washington Post:

Here is my students’ To Do list:

1. Do not attend class, unless attendance is specifically required.

2. Complain about the (modest) number of class hours requiring attendance.

3. Resist discretionary learning opportunities, no matter how interesting.

“Their logic is impeccable,” she admits. Cramming for multiple-choice tests in isolation “works beautifully in achieving the desired outcome of a good Board score. But what is the desired outcome?”

Medical students drown in minutiae they are told is irrelevant by real-world clinicians even as they are compelled to study it. Meanwhile, they are lucky to get anything more than an orientation presentation, mindless online module, or small group discussion on what seems fundamental to a good and just medicine: resisting the bureaucratization of the medical profession, engaging patients’ religious and spiritual needs, interrogating the enduring reality of medical racism, learning about how modern medicine understands suffering, examining the birth of “evidence-based medicine” in the early 1990s and how that epistemology equips (and constrains) the medical mind, or practicing presence with patients in a system that seems to allow only for the practice of absence.

“Medical training falls short of preparing physicians to help patients with the metaphysical needs of their illnesses,” write physicians Aparna Sajja and Christina Puchalski. Duke palliative physician and ethicist Farr Curlin puts it pointedly: “In medical training we never talked about what medicine is for, nor about how to become the physicians we knew we were called to be.”

Medical historian William G. Rothstein wrote in 1987 in American Medical Schools and the Practice of Medicine: A History that “‘Physicianship’ is nowhere taught in most medical schools. There is no course in ‘how to be a doctor.’” Nominally, today, every medical trainee receives some type of instruction in “medical ethics and human values,” as the Liaison Committee on Medical Education, an accrediting body, puts it.

But for most medical students, what it means “to be a doctor” is largely irrelevant to being a doctor. As a student, I did not have the slightest idea how to walk alongside patients in their suffering, but I did become pretty good at answering multiple-choice questions in ninety seconds. As a resident physician, I’m learning quickly that being a successful doctor in 2020 is similar. Today, medicine has more to do with efficiently processing patients like car engines (“treat ’em and street ’em,” as I’m told) than attending faithfully to patients as whole persons. When we doctors discuss “empathy,” it is because we know it is effective — apparently, displaying at least forty seconds of compassion per patient encounter gets the patient to do what we want. It is literally deemed more important that I know what to bill for than what medicine is for. As physician Anne Lifflander put it, “We have rendered the questions meaningless (although still reimbursable).”

It has been my experience that most students come into medical school asking important and difficult questions about the practice of medicine and the vulnerability of patients, and it is those students to whom medical school has little to say. They emerge from their education with their souls impoverished by the process just as their wallets are impoverished by their student loan debts — deformed, malformed, and habituated to see themselves rarely in the context of serving patients or flourishing as human beings, but at the level of identity relative to some dull combination of board scores and ranking lists.

“Their poor education has impoverished their longings,” wrote Allan Bloom in The Closing of the American Mind, his 1987 classic on the flattening of liberal education to professional training. This same tragedy is playing out in medicine.

Much of medical training necessitates doing something without knowing why, and, at times, doubting the way something is being done but doing it anyway. The sheer volume of information, worry about matching into a good residency, power of the institutional and social hierarchies, and sneaking awareness of constant evaluation sustain a sort of learned helplessness. Trainees learn to follow orders without questioning them. Medicine is militaristic in this way.

Upton Sinclair said, “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” It is difficult to get medical students to discover something when their board scores depend on them not discovering it. A physician once told me that practicing a just and better medicine will probably look like seeing fewer patients and taking a pay cut. I remember thinking that, for a student, “taking a pay cut” probably means scoring lower on exams. It might mean disrupting the workflow by experimenting with alternative practices of presence and formation that “waste” time. When time is so short already, that is a steep price.

When I ask medical students and their educators about formation, they often appear puzzled — is he talking about uterine malformation, in which fetal limbs become twisted due to strangulation or pressure in the womb? The assumption is fitting, as medical training can often feel suffocating and crushing. The womb of today’s medical school is not a healthy place to grow.

Whereas education is about learning something else — yet another piece of information — formation is about growing into and becoming something else. Like the potter with his clay, it is also a warning of permanence. Kilned clay will not easily yield without cracking, and bones that are broken will ossify however they are reset. The persons, practices, and places we inhabit and engage tend to shape and form us in their likeness. People grow into whatever space they find themselves within, like roots taking on the shape of a pot.

My wife has filled our home with devil’s ivy and mother-in-law’s tongue — perfectly fitting names for the only plants I seem unable to kill through sheer neglect. She has taught me that house plants require careful and consistent watering — assessing the dampness of the soil, color of the leaves, and proximity to sunlight. They can’t be lovingly potted once at the beginning of the year and then watered a year later.

Yet most formation attempts are that sporadic, peppering the fresh trainee with a few dashes of professionalism-and-humanities talk and then, four years later, desperately trying to tie up any ethical loose ends with another contrived exercise that overlooks the philosophical, ethical, and moral wilting of the intervening years. The sum total effect is akin to pushing together random pieces of a vocabulary of humanism like poetry magnets on a fridge and hoping that the result is somehow transformative.

It’s true that most American medical schools have a chapter of the Gold Humanism Honors Society. Many have a lover of William Osler (the father of modern medicine) or a humanistic professor who bedazzles with inspirational quotes and stories. Elective courses like physician Rachel Naomi Remen’s “The Healer’s Art” are already celebrated for seeking authentic change. Physician Rita Charon’s wonderful narrative medicine movement literally asks the question, “What might medicine be for?”

But these elective courses are optional — implying that this type of vocational self-study and creativity is itself somewhat arbitrary. While interventions designed to counter burnout or the hidden curriculum already report positive changes in humanism, observational studies suggest that no fundamental or practical changes in the lives of medical students actually last.

Bioethicist Jeffrey Bishop takes aim at this — what he calls “a therapeutic course of humanistic education, a humanities pill to fix what ails us.” The very analogy demonstrates that

it is virtually impossible to think about how to solve any problem in medicine without our thinking becoming almost immediately mechanical and instrumental. We already live inside a way of thinking that prevents us from thinking differently; not that thinking differently is impossible, it is just difficult. It we are to prevent all practices in medicine from becoming thoughtless doing, we must once again turn to how we think about what it is that we do.

Rather than electives or isolated experiences, today’s medical students need communities of parallel formation that stay with them through all four years. Physician Shaurya Taran hinted at a vision for this during my third year of medical school, in 2017. I remember coming across his Lisboa Café initiative and feeling my heart drop, wishing I had experienced something like this in my training. Instead of “formal classroom-based discussions about feelings and endless PowerPoint presentations,” he described regular monthly meetings that would ground medical trainees in “something more than just their work. The Lisboa Café initiative does just that. It is not an excuse to fill some touchy-feely deficiency in the humanities curriculum; it is meant to encourage the kind of self-study that, ultimately, returns us to the hospital as more wholesome physicians — ready to fulfill the obligations expected of us.”

A similar initiative exists at Loyola University School of Medicine. There, the Physician’s Vocation Program follows the medical student throughout his or her training, “exploring one’s self-identity at the intersection of faith and medicine. Through academic coursework, spiritual formation, a commitment to service and prayer, and conversation with classmates and faculty, the Physician’s Vocation Program seeks to foster and explore medicine as a calling.” This program complements the medical curriculum with the practices of the Ignatian tradition, informed by an understanding that the world is broken and largely cannot be changed, but we must love our neighbors with intent and creativity, and that is sufficient for the day. This is a community with an explicit moral vision.

At Duke Divinity School, the Theology, Medicine, and Culture Fellowship offers formation for those committed to engaging health, illness, and disability in light of the Christian faith and tradition. In 2016, just as I was considering quitting medicine and clinical work altogether, I took a leave before my fourth year of medical school to join this fellowship along with other medical students, pre-meds, nurses, practicing physicians, seminarians, and public health students. The fellowship required sacrifice — taking out additional student loans, leaving my friends, moving my family to a new state, and pushing graduation and residency back an extra year.

But that year changed my life. I returned to medical school seeing, at last, what medicine is for and who I was becoming within it. I discovered practical habits to pursue the type of doctor I hope to be for my patients — a doctor who can lament, who practices presence, who pursues technical excellence, who can attend to the problems of modern medicine and name them candidly, clearly, and with humility. I was charged with hope in medical practice, but also burdened with a sense of just how broken modern health care has become and how exasperated so many patients and physicians feel, and with the work and creativity that will be required by all of us to take responsibility for the healing of the profession.

There are doubtless many medical trainees and educators who would welcome similar visions of parallel formation. But for most students today, such a thoughtful respite is not a realistic option, even if it is a beautiful one. Not many will have the time, resources, or frankly the motivation to dedicate a year or longer to this kind of work. Few pre-meds will want to delay acceptance to medical school or risk deferred acceptance, and few medical students will be able to postpone residency and income.

Moreover, not every medical worker will find such distinct initiatives attractive, coherent, or even appropriate. Not every patient will desire a physician who was formed in a religious milieu. The specifically Christian practices of the Loyola and Duke programs are likely to strike policymakers and curriculum designers as too idiosyncratic to be practical. Today’s medical spirituality projects favor moral “neutrality” over moral particularity.

But within that friction also lies the flavor: a “neutral” version of the Physician’s Vocation Program would strip it of the very moral resources that make it what it is. Much of the transformative force of these initiatives is inseparable from their doxology. For me, when I see patients and understand them to be bearing in some mysterious way the body and sufferings of Christ (“I was sick and you took care of me,” Matthew 25), that vision makes a claim on me. It compels me to regard even the most frustrating of patients with neither rose-colored optimism nor jaded cynicism. It encourages both honest lament and practical action, because I am interacting not merely with a health care “consumer” but with a child of God.

It was only through time spent with disabled friends at Reality Ministries during my fellowship at Duke that I was changed in how I see the dependency and vulnerability of my patients (and myself) in an age that increasingly favors independence and autonomy. I was profoundly moved and humbled when a young woman who will never leave her wheelchair prayed for my formation as a physician. A PowerPoint slide can’t do that.

The task at hand is this: to build small communities that put medical students in relationship with others who capture the imagination, ask difficult questions with kindness and candor, and form new habits and practices toward a just and better medicine. Some of these communities and persons will be grounded in metaphysical and religious seriousness. Others will try again at something literary, ethnographic, or technological. Each effort may inspire others. As David Brooks writes, “Culture change happens when a small group of people find a better way to live and the rest of us copy them.”

In my final year of medical school, I began a group called Phronesis. As Alasdair MacIntyre explains, phronesis (“practical wisdom”) originated as a term of aristocratic flattery, characterizing someone who “knows what is due to him” and “takes pride in claiming his due,” which inspires less the image of a wise medical trainee than that of a shrewd mob boss. But through Aristotle, phronesis came to mean the knowledge of “what is due” in any given situation. In other words, practical wisdom is less like knowing facts and more like knowing how to read the room.

This kind of prudence is “the indispensable virtue for medicine,” wrote bioethicists Edmund Pellegrino and David Thomasma in their 1993 book The Virtues in Medical Practice. Clinical professor of family medicine H. S. Wald thinks that phronesis is foundational to “the becoming” of the physician. Theologian and psychiatrist Warren A. Kinghorn likewise argues that phronesis should be the goal of medical formation, in which medical students learn the intellectual content necessary to practice good medicine, while simultaneously binding that content to the moral virtues needed to use their knowledge justly.

Inspired by the Lisboa Café and my experience at Duke, I designed Phronesis as a parallel community and curriculum alongside all four years of medical study. We organized our content around ten key conversations conspicuously absent from medical education. We met in a local coffee shop once a month in the evenings, and at every session we asked two questions. First, “How are we being formed or malformed within medicine?” And second, “How should we then live and practice with wisdom?”

Here is a brief example from our first session: The evening’s topic was “Beauty, Awe, and Wonder as the Beginning of Wisdom.” We read two poems from Wendell Berry alongside David Bornstein’s essay “Medicine’s Search for Meaning.” We shared our first moments of wonder calling us to medicine and lamented the atrophy of our awe in medical training. We asked each other why this atrophy and malformation happened, but we also asked how we might recapture wonder. We closed the evening with practical wisdom: One student mentioned a small stone in her scrub pocket to help her “stay awake” and remember beauty in the hospital––not to escape ugliness but to attend to it in love.

In our fourth session, “Medical Professionalism and Moral Formation,” we brainstormed the idea of a “moral apprenticeship” — each of us openly identifying a physician whom we admired and committing to the practical step of asking them to mentor us — not over a single cup of coffee once a year, but through intentional meetings once or twice a month.

In our eighth session, “Learning How to Die: Religion, Theology, and Spirituality in Medicine,” camaraderie and familiarity had been established. We shared stories of those we had seen die poorly and those we had seen die well, including stories of friends and loved ones. We discussed how practices like prayer or silence at the deathbed, if appropriate, can be done with grace. We imagined “remembrance traditions” — can we somehow honor the names of those who have died during the week with silence at the beginning of Friday rounds? Will our upper levels and attendings tolerate such a waste of time?

This little initiative taught me three things: First, medical students feel their minds closing. They readily nod to this sort of metaphor, and do not find it overly abstract or alarmist. They only need the space to name their formation and explore it — often to grieve. At the same time, I stopped counting the number of times students used the word “healing” to describe Phronesis.

Second, Phronesis drew out students and local physicians who sensed a spiritual impoverishment in themselves and saw that something must be done. It attracted not only religious folks, idealistic first-years, or bookish bioethicists, but students and practitioners with profoundly different moral convictions and interests. Most of them were not previously acquainted, but the dehydration of their souls led them to the same spring, from which they emerged as friends. Despite the long hours, moral fatigue, and isolation that can come with modern medical training, a community of physician learners committed to creating a space to bring attention to their formation — drinks at their elbows, huddled together almost in secret — sharing something like good news: Though there is much brokenness in medical training, healing and reformation are possible.

Third, I realized that my reflections have been centered far more on the crisis of meaning in today’s medical students than on the suffering among today’s patients. This very essay betrays a nearsightedness toward the sickness of my own profession, despite taking an oath that binds me to seek first the health of the sick. This may well be the most painfully incongruous quality of medical student formation today, and it leaves me wondering whether it is only patients themselves who will teach us practical wisdom and open the medical mind.

Now is the time for us to pay attention to how we are being formed and malformed within medicine — and to see the patterns of brokenness that continue to manifest in health care. The coronavirus pandemic has only exposed and exacerbated this need, calling us to build parallel communities of deep listening, thick conversation, and new habits.

In addition to being slightly nearsighted — literally — I have an eye condition in which the spindled muscles holding my lenses struggle to relax. My ophthalmologist told me that my eyes became so used to studying without breaks during medical school that I actually began to lose my ability to see clearly, simply because I lost the ability to fully relax my eyes. He added that this problem will worsen as what I see gets darker.

How terribly appropriate it seems, that the more I’ve stared at my medical texts, the less I have been able to see. And the darker things get, the worse the myopia becomes.

I doubt that the opening of the medical mind will crack a window onto some bright and promising horizon. Rather, I suspect it will require a slow accommodation of focus revealing a blurry landscape that demands much love, work, and friendship. There, physicians and medical educators might find themselves enjoying the practice of medicine again. Students might long again to enter the profession. Who knows — I may even recommend medicine as a career to my own sons.