Asking the Second Question
Notes from a Family Meeting, Vol. 4, No. 5
“One senior resident once presented a patient in morning report and, as part of the physical examination, mentioned a scar in the patient’s groin. When I asked how the scar had been acquired, she said, ‘He told me he was bitten by a snake there.’
‘How did that happen?’ I asked.
‘I don’t know,’ she said.
How could that be? How could one not ask? The imagination runs riot with the possibilities of how this man got bitten by a snake in the groin. But the resident was too busy (or not curious enough) to ask!”
So Faith Fitzgerald, in her well known essay, lamented the state of curiosity in medical practice. Lest we think she was just picking on trainees, she goes on to describe an error of her own misdirected attention:
“Technology is wonderful and seductive, but when seen as more real than the person to whom it is applied, it may also suppress curiosity. When I was a house officer and installing one of the first rightheart catheters, the machine that showed intrapulmonic arterial pressures was enormous and was equipped with strain gauges rather than computer chips. Making it work was difficult. After the line was in, the attending, the nurse, and I tried desperately to adjust the machine to show the pulmonary arterial pressure waves. We could not get them. The line on the screen remained flat. We manipulated toggle switches and strain gauges for about 15 minutes. Nothing. Finally, I glanced at the patient: He was dead. We had been so engaged with the machine that we had missed this significant clinical event, which explained why the pulmonary arterial pressures were unobtainable. We assumed that the answer to the question lay in the machine and explored no further until it was too late.”
Sometimes we’re distracted by something novel, sometimes we’re distracted by the status quo. Paul Bergl defined it as:
“Baseline (noun) — (1) A preexisting condition requiring no further explanation; a prima facie diagnosis irrelevant to immediate therapeutic goals; a curiosity killer.”
For one patient, house staff shrugged and attributed some problem to the “baseline,” so Bergl did a chart biopsy: he combed through progress notes and discharge summaries to understand this patient’s history as documented by other clinicians. That is, after all, what we hope the chart is for. “It seems that no one,” Bergl grumbled, “has taken the time to cohesively synthesize Mr. D.’s myriad problems; instead, physician after physician has unthinkingly accepted his ‘baseline.’” He provided another definition, this one informed by the efficient metrics of inpatient medicine:
“Baseline (noun) — (3) A therapeutic target unto itself, the functional outcome that maximizes the likelihood of hospital discharge.”
He knows he needs to keep things moving. Bergl himself, despite his frustration, succumbs to the processes of intensive care medicine. He glowers from his helplessness.
What Fitzgerald and Bergl both resisted was a new world that was eclipsing the world they had learned to see and love. The clinicians of this new world saw, attended to, and cared about different things. That manifested as a stark lack of curiosity about the old world. Curiosity about one thing and not another will not only lead you to choose differently, but shape your options in the first place. Curiosity guides and shapes all our second questions.
How?
Iris Murdoch, considering the nature of choice-making, wrote:
“I can only choose within the world I can see … If we ignore the prior work of attention and notice only the emptiness of the moment of choice we are likely to identify freedom with the outward movement since there is nothing else to identify it with. But if we consider what the work of attention is like, how continuously it goes on, and how imperceptibly it builds up structures of value round about us, we shall not be surprised that at crucial moments of choice most of the business of choosing is already over. This does not imply that we are not free, certainly not. But it implies that the exercise of our freedom is a small piecemeal business which goes on all the time and not a grandiose leaping about unimpeded at important moments. The moral life, on this view, is something that goes on continually, not something that is switched off in between the occurrence of explicit moral choices. What happens in between such choices is indeed what is crucial.”
Choice is the final movement of decision. Decision itself is just one aspect of attending. We are, in part, responsible for how we attend, and so we’re also responsible for how we decide. The extent to which we can direct our own attention is what Thomas Aquinas called studiositas, the virtue of paying attention well.1 By “well” I don’t mean precise or sustained (though those may be the case), but that the attention is directed toward that which it’s owed and in the right measure.
The corresponding vice, curiositas, helps us better understand the virtue. Curiositas can drive us…
…to neglect duty. Innocent, even good, inquiries can lead us astray into noble procrastination. Any academic who adds on “just one more” project before finishing the other three knows this well.
…to ignore the tradition from which we should learn in favor of other, foolish, even dangerous, schools. Occasionally you might hear of a physician who strays into practicing homeopathy, for example.
…to ignore or supplant the telos of that which we study. What is renal function, for example, ultimately for except to serve the health of the person as a whole?
…to attempt to learn that which is beyond our capacity to grasp.
So studiositas requires fortitude, moderation, wisdom, and humility, to name a few other virtues.
Fitzgerald’s and Bergl’s residents, as well as Fitzgerald and Bergl themselves, despite being smart folks, struggled to attend well. So, too, the pseudonymous Wilson Dunlop:
“Just two weeks into my third-year of medical school, I committed a grave sin. I was alone in my room on my laptop, familiarizing myself with the software that powered the electronic health record (EHR). It was like any other night—a mixture of laziness and productivity and needless juggling between my electronic devices—except on this day a thought crept into my mind while using the EHR’s search engine. ‘Can this thing look up anybody’s medical record?’ I got curious, and it led me astray. Next thing I knew, a friend’s face popped in my head, likely from having just seen this individual’s Instagram profile on my downtime, and I started typing. To my surprise, the friend’s name showed up in the search field. I hesitated. I was tempted. And with one simple click, I fell down a rabbit hole I wish I never knew existed.”
What happened, again and again, was in Dunlop’s estimation just “a lapse in judgment.” They “made a mistake. [They’re] not a bad person.” Nevertheless, hounded by guilt, they were driven to look inward and then cast apologies outward. This snooping, they came to learn, wasn’t just a mistake; it was a grave harm committed against those trusted that their information would be held in confidence. Although it was a harm for which they were culpable, it was also a harm they were bound to commit. They had no studiositas and so they were drawn to curiositas.
I suspect what Dunlop did isn’t common, though the essay highlights the links among boredom, power, and wrong-doing, and how some people attempt to manage that. Fitzgerald’s frantic fiddling with technology while someone‘s dying happens every day though. Bergl’s residents, disengaged from one set of questions and guided by others, can be found on any hospital ward. Pitfalls abound:
Clinicians can neglect their duty of pursuing their patient’s health. They’re like the Dodecahedron, flourishing right answers to the wrong questions. I’m not discounting the many times clinicians thread the needle in an attempt to save someone’s life, when everyone knows the stakes are high. Surely that’s what Fitzgerald was trying to do with the right heart catheter. But while she did, she wasn’t asking other questions, like, “Is this what a dying person needs?” Or we can chase after metrics, running right past health. Some clinician-scientists care more for their research question than for their patients. Sometimes the questions afforded us by pathophysiology, concrete as they are, draw our attention. Other questions, whispered in helplessness by human frailty, vulnerability, and mortality, often more relevant to health, just get boxed out.
Clinicians can neglect history. What voices do we neglect in our education that could inform our understanding of health? What voices do we elevate that lead us astray from pursuing health? Why is this person of color so guarded and distrustful? How are the hopes placed in AI similar to early hopes for the EMR? In most medical training, there’s a null curriculum around health. The presupposition is that health is just the homeostasis of physiology, but this neglects the actual human experience of health as documented in fiction, non-fiction, poetry, and all kinds of art - different traditions. Electives and occasional noon conferences attempt to acknowledge this, but everyone knows hyponatremia is on the test and knowing how to manage it is far, far more important. We walk past some teachers to sit before others.
Our medical interventions twist in our hands and don’t aim for health. Purposeless activity, anchored so often in “respect for autonomy,” harms people. We can then lose sight of what health is even for (whatever bit of we have) and degrade our bodies. While we, in a pluralistic society, may not reach a definitive answer to that latter question, it’s worth discussing. Health as an end unto itself can become totalizing.
Clinicians can ask questions that are beyond them. When I was an intern, I marched through a checklist of symptoms while evaluating a patient in the emergency department, some of which about trauma that didn’t need to be asked at that particular moment. Other questions blur the line between therapy and enhancement. Sometimes the questions not asked ignore the limits of what’s possible.
Attending with Better Questions
Attention of clinician and patient alike are siphoned away by the many blood-sucking mosquitos of our healthcare system. Constant distraction induces helplessness and shapes how we see the world, ourselves, and one another. Joel Shuman remarks, “Questions about the ends of human life, having been relegated to the realm of personal subjectivity, have been subordinated to the dictates of instrumental reason to such an extent that the indefinite expansion of technological control in service to individual wills has become largely determinative of the ends of human life.” The tail wags the dog.
This is a distraction, and one for which we’re culpable. It’s curiositas at work when we run after only those questions supplied to use by our technology and ignore the greater, deeper questions of “the ends of human life.” Shuman supplies a response: “…a body seen as a body—both more and other than the sum of its parts—is one seen as the manifest presence of a beloved human person instead of simply as an object to be manipulated or controlled.” He goes on, citing Wendell Berry:
“There is an element of mystery here, in the sense of an irreducible wholeness that exceeds the anatomical gaze: “The body, ‘fearfully and wonderfully made,’ is ultimately mysterious both in itself and in its dependences. ... We are not going to know about this,” at least not in the sense of knowing extended by analysis.
When all is said and done, bodies are seen and known well only insofar as they are loved, and they are loved only insofar as they are seen and known well. The body seen though the anatomical gaze is reduced to a manipulatable object or collection of objects. A body so seen is … a body seen only partially and incompletely and therefore a body unworthy of love. The challenge for those who would participate in the healing of broken bodies is patiently and diligently to cultivate the habits of body and mind requisite to this seeing and loving.”
A challenge indeed.
The deck’s stacked against clinicians and patients, and maybe against all of us. Technologies can insert themselves into the relationship between clinician and patient: the medical record, metrics, even medical intervention itself. Sometimes a pill is not what’s needed, but presence. Businesses (some of which are hospitals, clinics, nursing homes, and other groups styled to care for people) wring money from the relationship. There are competing agendas: how does a research institution balance caring for their trials with caring for their patients? How do you respect patients’ wishes while at the same time ensuring you’re doing enough transplant surgeries to keep the program funded? How do you get more organs for that program (er, for those patients…)?
Dunlop’s misdirected attention drove them to psychotherapy. If Fitzgerald, Bergl, or their residents did the same, they didn’t comment on it or relate it to their challenges in attending. Psychotherapy is one way to learn how to redirect one’s attention, but it’s not intended to develop studiositas. Cultivating mindfulness, a focus of some psychotherapies, may help with studiositas, but it says nothing about that toward which you should direct your attention (should I write the great American novel or do the laundry?). Nevertheless, insofar as you could take a class on writing (without being directed about that which you should write) or watch a YouTube video on laundry (without being guided on what clothes you should wear), so, too, can learning mindfulness contribute to the deeper work of cultivating studiositas.
One practical lesson of mindfulness practice is the reduction in attention to just one thing. Rather than add something, we take away. Norman Wirzba, writing about being able to discern one’s calling for their life, asks:
“…is it possible that our culture, because of the priorities and plans in life that it models for us, may actually make it more difficult to hear the voice calling to us?
This may sound strange, for few of us are likely to admit that we are hard of hearing. But hearing is, indeed, one of our most pressing problems. We live in a culture that saturates us with one over-riding message: the world belongs to us, is ours for the taking, if only we exert our skill and ingenuity. Everywhere we look, whether we examine our living spaces, the media, or even our churches, we see the significance of ME! Everywhere we turn, we are reminded of the opportunities to satisfy self-chosen ends and desires, and the importance of doing so. In this world there is little room for another (even the Holy Other) to appear as genuinely other, and thus little chance that same voice will register as distinct from my own and will be heeded as in some way authoritative or determinative for my living.”
He goes on to list five ways modern culture turns up the white noise and limits our ability to hear others. Wirzba argues that
“…we need to overcome the alienation, insularity, fear, suspicion, arrogance, ignorance, and inattentiveness that often characterize our relatedness to others. We need to develop concrete, sustained practices that will bring us into closer and deeper proximity with one another, for it is out of this intimacy that we will see how we need each other and how we benefit each other. We will also come to listen better, gradually to hear the other’s call to us, and thus find our lives inspired, directed, and corrected.”
Wirzba, relying on Albert Borgmann, recommends the development of “focal practices,” which are activities that “draw us more deeply into the complexity of reality because, as we are drawn in, the world in its details and mystery now becomes illuminated for us.” He gives the example of a family meal, which starts with someone lovingly preparing the food, then everyone sitting down together to share about their day. This is a far cry from everyone rushing their own way while scarfing down fast food.
At the root of a focal practice is a kind of letting go. In order to be attentive toward another, we need to allow our own thoughts and agenda to be interrupted, if even for a few moments. It’s in that interruption that we can behold the beauty of others, love them, and so attend to them well.
What this means for clinicians, then, is that for a few moments in a day, we could stop relying on the medical record, the laboratory values, the physical exam. Like walking into an ancient cathedral, our silence allows space for awe. So, too, when we behold patients as they are: living cathedrals.
Who knows what might arise out of such a space, but you need only experience it once to know it’s a space worth holding. I suspect that out of such a space, when the time for speaking recurs, the “second question” we’ll be inclined to ask will be quite different from the one we were going to ask from our checklist a few moments prior.
What a privilege to be here, now, with these people, tasked to help and accompany them. What testimonies of human resilience, hope, and love will we behold in such moments? To the extent that we feel we can’t do that because of one reason or another, can we find the resolve to want to do it? Can we even want to want to do it? Can we find the wherewithal to attempt to hold the space so that such wonder would be possible?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“Talk less: The risk of over-communication with seriously ill patients”
These authors describe three situations in which it might be wise to talk less (or not at all): revisiting a sound decision, repeatedly asking a question when a patient hasn’t given a desired answer, and asking questions that shouldn’t be asked. They center their brief exploration around code status, but this points can apply to all sorts of clinical situation. However, they need to be anchored by the goals of care, the limits of medicine, and the purpose of medicine. Without those anchors, “less is more” becomes efficient deception.
Paul Kingsnorth, relying on Simone Weil, reflects on the need for roots, and the rootlessness of our modern age. Why are we rootless, and how can we return to rootedness? Can we? Should we? “When a plant is uprooted, it withers and then dies. When the same happens to a person, or a people, or a planetful of both, the result is the same. Our crisis comes, I think, from our being unable to admit what on some level we know to be true: that we in the West are living inside an obsolete story. Our culture is not in danger of dying; it is already dead, and we are in denial.”
“Three Challenges for Talking About Health”
Brewer Eberly, in reviewing Sandro Galea’s book about health, laments the challenges we have in even talking about the topic. He ends by remarking, “Absent caritas — what Galea names “a desire for love” — and the traditioned communities that make that love coherent and possible, we will not be able to achieve health, let alone change what we need to talk about when we talk about it.”
“A Prophecy of Evil: Tolkien, Lewis, and Technocratic Nihilism”
Reflecting on the work of J.R.R. Tolkien and C.S. Lewis, N.S. Lyons (a lot of abbreviated names here) reflects on what it means to be totalitarian. Such an impulse, in one estimation, is found in anxiety provoked by disorder. “For Sauron, the ‘confusion’ and ‘friction’ he could not tolerate was the product of the unpredictability of the free will of other living beings, and so it was all ‘the creatures of earth, in their minds and wills, that he desired to dominate.’ This led him to forge his own technological devices of total control: the rings of power and the ‘One Ring to rule them all.’ His single-minded need for order – ‘swollen to madness’ in its isolation – had cut him off from humanity…” Such totalitarian impulses are also found in everyday modern anxieties stretching for ever-greater control.
“Hospice Care’s Midlife Crisis”
A helpful summary of some of the problems facing hospice care in the United States and where there are opportunities for change. I’d be interested to hear how things are going in other countries.
Closing Thoughts
“Practice can survive without theory while theory arises from a practice and perishes without the nourishment of a practice.
Albert Borgmann, Power Failure
Sometimes folks cringe when discussing virtues in modern medicine. All the more so if you’re citing an ancient Roman Catholic theologian. Let’s keep in mind, though, that an accessible understanding of “virtue” is simply those characteristics necessary for a practice to reach its end or purpose. In order to be a good clinician, for example, a person needs to be… what? The characteristics you list are virtues, and those things that detract from the practice are vices.