Wisdom
Notes from a Family Meeting, Vol. 2, No. 5
Clinicians can be so foolish sometimes.
One of the most classic tell-tale signs of medication non-adherence is when a patient is admitted to the hospital for serious blood pressure problems (hypertensive urgency or emergency), their home anti-hypertensive regimen is restarted, and they become hypotensive in short order. The medications may have worked if the patient had actually taken them, but the doctor in the clinic just kept increasing doses in response to high blood pressure readings without ever thinking that the patient might not be taking them for some reason.
It was one such patient who drew the ire of the physician with whom I was rounding one morning. Why couldn’t this patient just take their medications as prescribed? As she stammered her questions and defenses, his voice rose steadily higher, trampling over her own: “You must take all your medicines. Bring them all to your doctors’ appointments so we know what you’re taking!” The pharmacist stood behind him, writing a summary in big letters on a whiteboard: “Take your medicines and bring them to the doctor.” The woman, alone and confused, didn’t have much else to say. She assented, though I doubted much would change. Satisfied, the physician left, sighing outside the room, “She must have dementia!” I have no doubt it was the physician, not the patient, who had acted foolishly in that whole encounter.
I may not have yelled over any of my patients, but there are times when I’m at my wit’s end and I dismiss a patient’s question or concern. Maybe I never come back around to it, I paper over it with questions of my own, or I only give the thinnest appropriate answer: a simple yes or no, banking on the authority of my office to limit any objections or further questions. In those times, I act foolishly.
Most people don’t want to act foolishly unless their career as a comedian depends on it. Certainly clinicians don’t want to act foolishly. And none of us want to be foolish with our own health, though the way we regard our health in relation to other goods in our lives may make us appear foolish. But it’s not enough to avoid foolishness. Just because you avoid the potholes in the road doesn’t mean you’re going where you need to go. What does it mean to be a wise clinician?
Rather than an exhaustive review, I want to situate a few lessons about wisdom in the context of what I’ve been discussing about the goals of care, health, and prognostication. I also don’t want to pretend I’ve reached the top of the mountain. Even from the valley, I can see the peaks and try to describe to my fellow travelers some of what is beautiful and good about them.
Wisdom in Medicine
Someone who knows facts, despite winning many a’game of Jeopardy, may not be wise. Nevertheless, wisdom requires knowledge. As first year medical students can attest, there’s a lot in the world of medicine to know. Having traced the humbling curve of the Dunning-Kruger effect, I now know there’s more in the world of medicine than I can possibly know. So, right there, we have two starting points: knowing some things about the world, and knowing some things about oneself. Medical education, then, is not just a pedagogy of pathology, but also a way of learning about yourself: your strengths, yes, and also your limits. Not just your own strengths and limits personally, but also those of your profession, as Matthew Crawford noted in Shop Class as Soulcraft:
“…the intellectual virtue of judging things rightly must be cultivated, and this is typically not the product of detached contemplation. It seems to require that the user of a machine have something at stake, an interest of the sort that arises through bodily immersion in some hard reality, the kind that kicks back. Corollary to such immersion is the development of what we might call a sub-ethical virtue: the user holds himself responsible to external reality, and opens himself to being schooled by it. His will is educated—both chastened and focused—so it no longer resembles that of a raging baby who knows only that he wants. Both as workers and as consumers, technical education seems to contribute to moral education.”
This can be broadened to include the clinician’s work with patients. Teachers in our school are the human body and its pathologies, every patient’s individual story, and the limits of the human condition. Bodies, minds, and even stories can be broken beyond repair. The cultivation of wisdom under the humbling discipline of reality is in tension with the ever-present urge to exceed our limits, particularly in medicine: how can we live longer, become more capable, and become more comfortable? The danger in failing to learn from limitation is that, in Crawford’s estimation, “we remain idiots.” The alternative is to achieve “an iterated back-and-forth between seeing and doing. Our vision is improved by acting, as this brings any defect in our perception to vivid awareness.” So, there’s a place for book-learnin’, but the best education for the clinician is in the actual practice of medicine.
Even that is insufficient, though. We need to know the good of things. For the clinician, what is good health? What is a good medical intervention? What is a good clinician? It’s easy enough for a chef to know a good knife: it handles and cuts well, helping her to make a good meal. It’s more difficult to know the good of things for clinicians because we spend less time (or no time) studying what health is and appreciating what makes a good clinician.
If we can’t behave wisely in medicine, then we’ll use our tools poorly. We may put them to the wrong uses, use them at the wrong time, or use the wrong ones. This is what Michael Sacasas meant when he pithily tweeted, “We’ve gone from creating tools to accomplish what we desire to desiring only what our tools can accomplish.” Relying on Ivan Illich and Jaques Ellul, Sacasas wonders if “the human-built world is, in fact, not built for humans.” That seems outrageous in healthcare. Who else would the world of healthcare serve? Healthcare is built for humans because humans are our patients! But there’s more to helping humans than merely appreciating their physiology and its deviations. When the cadaver becomes the normative symbol of practice (an entity frozen in space and time, totally patient under the unyielding analytical gaze of the beholder), then what we have is no longer a healthcare system, but a disease-care system untethered from wisdom. In clinics and hospitals, we watch lab values go up and down in response to various therapies while people suffer and die behind a veil of those healthy-appearing numbers for want of a wise clinician.
This can’t be a product of medical lectures, like you might teach a physiology class. These things are more “caught” than “taught,” as noted by Warren Kinghorn: “…it is unreasonable to expect that students and residents will develop the excellences of professionalism [one of which is wisdom] if those excellences are not valued by and embodied in their teachers.” It involves cultivating one’s capacity to see well. Seeing well, in this sense, is a whole body endeavor, becoming attuned to one’s own affective and enteroceptive responses to other people. Seeing well is just as much a moral endeavor as a technical endeavor. Joel Shuman writes of this:
“…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. … 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. … 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”
You can see, I hope, that compassion and wisdom go hand-in-hand here. Compassion is the urge to help someone who suffers. We see them as a “someone,” not an “interesting case,” or “difficult patient,” or vehicle for a disease that is actually the focus of our interest. Wisdom without compassion makes the clinician too aloof to be helpful. Compassion without wisdom makes the clinician at best useless, at worst dangerous.
J. Donald Boudreau and Eric Cassell, writing about medical wisdom, note that the differences between techne (“application of technical knowledge to a particular context”) and phronesis (“the capacity to make good judgment calls”) are relevant to the clinicians’ work. This comes up in a number of places, chief among them being able to move between generalizing and particularizing. Relying on others’ work, they remark:
“Kathryn Montgomery Hunter describes the need for clinicians to cultivate a bifocal cognitive perspective: ‘Clinical reasoning in medicine has, of necessity, two aspects: generalization and particularization. These are opposite moves—lumping and splitting—and they alternate in tension as the reasoner moves between them . . . . This counterweighing is the central characteristic of clinical judgment.’ In accord with Hunter, philosopher Joseph Dunne has said of judgment that it lies ‘in the mediation between general and particular, in the ability to bring both into illuminating connection with each other.’ The ability to identity [sic] commonalities across cases, to discern patterns, and to apply generalized propositional knowledge to particular cases is undoubtedly necessary for competent medical practice. Informed by the tenets and scholarly products of evidence-based medicine, physicians appear to be adept and at ease with processes of generalization. When suboptimal practices occur, it is often a result of a failure in apprehending the particulars of a case.”
The most straightforward example of this generalizing-particularizing dynamic is using medical evidence to help an individual patient. You understand the generalities of how medical evidence applies to the human body in theory, but then you particularize that evidence to the unique circumstances of the patient before you.
Wisdom and the Goals of Care
In regards to the goals of care, we know they are longevity, function, and comfort. That is the general reality. Sometimes we use medical technology for other things (I’ve previously discussed death, and will take up enhancement later), but in aiming at the good of health, medicine can really only intervene in those three ways. It’s one thing to know the generalities of those objective goals and what can be done, in theory, to pursue them. It’s another to navigate the conversations to help patients prioritize among them in the midst of serious illness to discern what should be done. What does it look like right now to prioritize and pursue longevity for this patient? Or function, or comfort? How can we attend to the other goals even if they’re not prioritized? All that requires wisdom. It requires a willingness on the part of the clinician to be, in Crawford’s language, held responsible to the external realities of both the general goals of care themselves as well as the particularities of the individual patient’s life. Those particularities are physiological, sure, but also social, emotional, psychological, and existential. They’re messy and gum up the pretty algorithms science provides us for clinical decision-making.
So, you need wisdom to be creative and flexible in pursuing a goal of care with a patient. Yes, on the one hand, a clinician needs to recognize limits. But on the other hand, the clinician shouldn’t be too quick to dismiss as impossible a patient’s hope. Maybe thinking outside the box will help a patient get to that vacation after all even in the throes of advanced cancer or keep their job in the midst of a severe and persistent mental illness. How might other team members help? How might creative prescription schedules help?
Nevertheless, wisdom does help the clinician appreciate the limits of their interventions in pursuing a particular goal. This is more than believing a patient’s desperate request is futile for the purposes they want to accomplish. Wisdom helps you discern how you might help this person even in the face of seeming futility. Wisdom, hand-in-hand with compassion, helps to temper the pain when you worry there’s “nothing more you can do” because it helps you realize that, in those moments, you can still walk with your patient through this, you can still be present with them. Your presence can count for a lot (but don’t overdo it - we also need to recognize when we’re only minor characters in this chapter of someone’s life).
Wisdom also helps the clinician to teach patients and families to not only advocate for the care they need, but to avoid those things that have a good chance of hurting them (as attractive as those things might appear). Orienting everyone around the goals of care helps to make this clearer: is this really going to help? What are the trade-offs?
There aren’t rules here. Do you see the tension between different poles of action? Instead, wisdom requires that the clinician constantly manage that tension between limitation and creative possibility in addressing the goals of care. In so doing, they develop the iterative practice Crawford described of moving between “seeing” and “doing” that refines wisdom.
Wisdom and Health
Health has two facets: the objective facet that is “well-working wholeness,” and the subjective facet that is the invisible cooperation of the body engaged in desired activity. Health is the integrity of everything that makes us who we are, and we most experience it when it allows us to be present to and have a relationship with the world and others.
We need wisdom to even see health - to see how all the parts of a human life fit together. It’s easy enough to treat hypertensive urgency divorced from any other consideration in the patient’s life. How, though, does that issue interact with the other parts of the person’s life? How can we restore this person to health, rather than just making the blood pressure trend in the right direction? We need to understand the risk of hypertension in causing serious health outcomes, yes, and also to understand social determinants of health and the drivers of non-adherence and the hopes and worries of the patient.
Seeing health is challenging because, as I mentioned, part of health is invisible, particularly to its bearer, but its loss is often felt deeply. Even still, that loss may be doubted if it doesn’t reveal itself in the objective facet of health. “Pain,” Elaine Scarry wrote, “is the most privately certain and publicly doubted phenomenon.” Wisdom and trust are linked, for without trust, we can’t appreciate the subjective realm of health for the patient and it will be that much harder to come together with them to work on this common goal of health. But too often that alliance becomes one of the patient and clinician against the patient’s body. It’s the body that has rebelled and become uncooperative, or else become a battleground for a war against cancer or infection. How can the clinician renew the patient’s pleasant partnership with their own body and thus restore some bit of the subjective facet of health?
Once we’ve seen health, we can discern how its been afflicted. We can begin to work together with the patient on how pursuit of different goals of care can help restore a measure of their health. We can appreciate how nuanced diagnostic tests are situated in the bigger context of someone’s health: it’s not about blood pressure itself, but what blood pressure means for this person’s health.
Wisdom and Prognosis
What is the point of offering a prognosis? We’re often not very good at it: we’re inaccurate and what’s offered is inevitably incomplete. Nevertheless, through research and experience, we get some idea of what the future might hold for someone facing particular health problems or interventions. People often want that information so they can plan, know what to expect, and account for it in their weighing of the burdens and benefits of medical interventions.
The clinician can fall into a ditch on one side of the road, giving a prognosis that’s too certain. When clinicians are too certain, they fail to recognize the limits of their knowledge and the inherent uncertainty of the future. Predicting how long someone might have to live is hard enough, but because of our bias in thinking of prognosis as time left to live, we overlook all the other ways we’re over-confident. For example, in talking up a particular intervention, failing to appreciate the burden an adverse effect has on people’s lives (“Three to four episodes of diarrhea per day isn’t that bad…”), or failing consider harms we haven’t seen in our own practice. All of that contributes to over-confidence. Clinicians might over-estimate benefit by orders of magnitude, believing that a medication offers a 50% reduction in risk of a particular outcome when, at most, it’s 0.5-1%.
There’s a ditch on the other side of the road too: offering no prognosis at all, or an incomplete prognosis. Yes, the future is uncertain, but in some situations we can chart a useful trajectory even if it’s not perfect. For example, someone with metastatic cancer who has stopped eating is going to die in the coming days to weeks. But that’s an incomplete prognosis and the most common version I see provided in the realm of serious illness communication. When I did more work as a psychiatrist, I would see prognoses hinge primarily on function and symptoms but leave out an appreciation for how certain conditions (e.g., delirium) might portend a shortened life expectancy. Incomplete or absent prognoses are a disservice to patients because they are left unable to plan about their future: whether it be funeral arrangements, caregiving, employment, durable medical equipment, or any number of other things, prognoses help patients plan.
A humble, holistic prognosis helps clinicians avoid either of these ditches. It’s humble because it acknowledges limits (recognize a theme?). Reality can be better or worse than the best or worst case scenarios one envisions. This prognosis is also holistic because it addresses time, function, and symptoms (to track with the goals of care: longevity, function, and comfort). That’s not to say a holistic prognosis needs to be rendered in every scenario (“The risk of your child dying from this ear infection is…”). But it should weigh in the clinician’s thinking so they can discern what components are most relevant in helping to guide their patient. Those maneuvers, too, require wisdom.
What do you think? In what ways do you learn from your own foolish missteps? How do you cultivate wisdom?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“After ALS struck, he became the world’s most advanced cyborg”
A fascinating look into the use of technology to support the life and function of someone with ALS. However, the use of the phrase “living corpse” in reference to the body with severe disability provides grim insight into what life is “worth living” (or even considered life). It’s even more concerning that this is framed by someone with the privilege to coordinate their care across many well-known specialists. Not everyone with ALS has those opportunities, if they’d even want them.
“Challenging the hegemony of the symptom: reclaiming context in PTSD and moral injury”
Warren Kinghorn observes that when “post-Vietnam syndrome” was transformed to “post-traumatic stress disorder” in the DSM, the diagnosis was broadened to include more people who suffered from trauma, but also continued in the wrong direction of over-individualizing trauma: “…to frame trauma structurally as an individual phenomenon, and to conceive of trauma healing as an individual project, is to interpret trauma too narrowly. Trauma…is almost never an individual matter in its origin; it is almost always inflicted and experienced in a relational and social context, whether of war or intimate relationships or workplaces or schools. Post-traumatic responses are intrinsically social and relational in nature, as individuals navigate and manage connections that have been challenged and disrupted in a traumatic context. Indeed, it is uncontroversial and well-established that group treatments can be deeply healing for trauma survivors, particularly but not uniquely in the case of combat veterans…” This is a problem because “…symptom-focused approaches…promote technical solutions and cannot distinguish between morally appropriate and morally inappropriate technical solutions.”
“Ensuring choice for people with kidney failure - dialysis, supportive care, and hope”
These authors note that end-stage renal disease is often painted in binary terms: dialysis or no dialysis. They want to broaden our horizons to better accommodate patients’ goals of care: could we do an easy transition onto dialysis, rather than jumping straight to the thrice-weekly regimen? Is there a role for palliative dialysis, with decreased frequency or intensity of treatment? I’ve cared for many patients who may have a comfort-focused plan of care but dialysis, though burdensome in its own right, helps to manage troublesome symptoms like little else can.
“Is ‘death with dignity’ really possible?”
Ronald Pies, an advocate against assisted suicide, highlights the frustrating flexibility of the term “dignity” in discussions around dying. It can apply to the baseline human identity, our capacities, or our moral choices, as well as other things. Nevertheless, the story he tells is one of someone who is disabled overcoming their limitations and doing things they wouldn’t normally be able to do - that is living with dignity, apparently. Until we can come to some shared understanding of what dignity is, we’ll keep talking past one another on these and other issues, but that wasn’t the highlight of his article. Instead, he compared the Jain practice of Sallekhana with voluntarily stopping eating and drink (VSED). I can't tell whether Pies is commending VSED by likening it to Sallekhana. However, Sallekhana appears not to have death as a goal, whereas VSED does, which makes them very different practices.
“PAS versus involuntary commitment: is there a moral dilemma?”
This paper is a response to another paper on this topic and receives its own response from the original paper’s authors. Ronald Pies and colleagues are careful to draw out how these two practices represent two fundamentally different responses to self-killing in our society. The question is: which one best accords with the practice of medicine? It’s worth noting, though, that the vast majority of people who avail themselves of PAS would not benefit from psychiatric hospitalization - either because they don’t have any mental illness at all or none that is acutely severe enough to improve during the “crisis stabilization” of a hospitalization.
“(Don’t) leave me alone: attachment in palliative care”
“Attachment styles describe how we seek our closeness and how secure we feel in close relationships.” Everyone has an attachment style, and most adults are “securely attached,” meaning they can generally navigate the messiness of human relationships with some degree of comfort and poise; importantly, this isn’t about being introverted or extroverted. This is in contrast to the variety of insecure attachments that develop when infant and childhood caregiving goes awry. Folks who are insecurely attached may still craft a comfortable life for themselves, but under the stress of serious illness, things go haywire. One thing I would add is that clinicians have attachment styles too, most of them being human. That humbles us in our temptation to believe that any chaos stems only from patient or family behavior.
An intriguing conversation among Adam Rodman (host of this podcast on the history of medicine), Agnes Arnold-Forster (UK-based medical historian), and Sam Schotland (US-based medical historian) on the history of burnout. The context within 20th century history is certainly helpful, and I wish I could have heard more. I do take issue with the lack of nuance in one of Dr. Forster's proposed solutions: "reconceptualizing healthcare labor as labor, not as a profession or vocation, but as a job that has limits and restrictions and can be delineated from your life." I don't disagree that clinicians should have boundaries. Most can't live at the hospital and dedicate their entire lives to the practice of medicine. Nevertheless, most of their waking hours will be spent in the practice. Medicine is a practice that aims toward some good (that is, health). In order to pursue that good properly with any hope of achieving it, we need more than technical mastery. We need virtues - those qualities that make this possible. I would say it's hard to inculcate those kinds of virtues if work in medicine is viewed no differently than, say, a mere job that one has just to pay the bills. Not there's anything inherently wrong with a "mere job," but medicine is more than that. When we divorce medicine from its rootedness in this kind of moral tradition that cultivates virtue, we ironically deprive clinicians of the resources necessary to sustain compassion and wisdom in the face of suffering, which fosters burnout, moral distress, etc.
“Incorporating pharmakon: HIV, medicine, and body shape change”
I discovered the idea of a “pharmakon” by stumbling across this song; the lyrics are deep and suggestive of its ambiguous meanings of both remedy and poison. There’s some literature out there on the idea, but not as prominently in the world of medicine as I thought there would be. In this piece, Asha Persson wrote about antiretroviral therapy as a kind of pharmakon, providing physiologic benefit while also carrying significant burdens. Since those burdens are not only physical but also social and existential, they don’t really fit within the biomedical model and therefore are poorly addressed by clinicians.
“Discomfort, doubt, and the edge of learning”
Greg Lukianoff and Jonathan Haidt, in The Coddling of the American Mind, wrote “…teaching kids that failures, insults, and painful experiences will do lasting damage is harmful in and of itself. Human beings need physical and mental challenges and stressors or we deteriorate.” They describe this idea as being “anti-fragile” - it’s not that humans are unbreakably strong like iron, but rather that they need the right amount and kind of stress to grow well. This idea is a very old one in education, captured in Plato’s idea of “aporia.” Learning can’t happen without discomfort as we grow and also bend or break old ways of thinking. This isn’t the rapid fire questioning that occurs during most daily rounds; rather, aporia, in the hands of a helpful educator, is used for the student’s benefit.
Parting Thoughts
“As the body breaks down, it becomes increasingly the object of attention, usurping the place of all other objects, so that finally, in very very old and sick people, the world may exist only in a circle two feet out from themselves; the exclusive content of perception and speech may become what was eaten, the problems of excreting, the progress of pains, the comfort or discomfort of a particular chair or bed. Stravinsky once described aging as: ‘the ever-shrinking perimeter of pleasure.’ This constantly diminishing world ground is almost a given in representations of old age.”
Elaine Scarry, The Body in Pain