Reflection on Presence: Part 2

Once, on a flight, I met an elderly woman who had the misfortune of needing a liver transplant when she was in her early thirties. She had just gotten married. Her husband (sitting next to her) recounted how their attending nurse, in a hurry to move onto other patients, had brazenly told the couple to “clean up their own bedsheets.” Then there were the annoyingly bright lights, the constant whirring of the machines, and the frequent noise disruptions from the 5, 6 other neighbors who were crammed into their room, that made it almost impossible to sleep. 

Meanwhile:

“Research over the last 10 years has shown that burnout – the particular constellation of emotional exhaustion, detachment and a low sense of accomplishment – is widespread among medical students and doctors-in-training. Nearly half of these aspiring doctors end up becoming burned out over the course of their schooling, quickly losing their sense of empathy for others and succumbing to unprofessional behavior like lying and cheating.” “The Widespread Problem of Physician Burnout.”

If these stories of patients and physicians count for anything,  there seems to be something  awry with the picture of medicine nowadays. That is to say, there is very little healing in medicine.

The central question is, why are doctors so bad at being present? Why is there so little opportunity for relationship, a space that not only allows physicians to give patients human care (that is, a kind of care that fights against the mechanizing, fragmenting tendencies of the modern healthcare system), but also allows the doctors to receive from their patients, becoming, in the process, more human themselves?

I wonder, though, whether we’re setting ourselves up for just that failure. I wonder whether medical education (and even before that, the premedical environment) is a tremendous bait-and-switch, preparing students for one thing, only to leave them, decades later, to find that medicine is entirely another.

Browse through any brochure or marketing material from the top medical schools and you will quickly see what I mean. They are full of language that I find disingenuous – a language that points to a technological utopia in which human will no longer have to suffer or die.

That is not all. The entire preparation process for medical schools trains students to think of medicine not as an endeavor greater than themselves, but to subjugate the field to the confines of their private ambitions. To attract the attention of premedical students, medical schools must now offer ample research opportunities (backed up by endless stores of NIH grant money), opportunities for leadership activities, opportunities to see the greatest diversity or extremities of clinical cases, opportunities to be placed into the best residency programs (whatever “best” means).  It is a continuation of what premeds have done all of their lives, which is to push forward a carefully crafted, highly individualized story that makes them a unique candidate for the medical profession. I am not merely finger-pointing here, because I am guilty of the same. And when faced with the decisions on which schools to apply to, or which school to ultimately attend, I admit I have very little guidance other than something like the US News & World Report rankings. God help me.

This has consequences. I once eavesdropped on a conversation a premed student was having with a stranger while waiting for his flight home from a medical school interview. The stranger asked him what he might want to specialize in. He replied, “Surgery. Because I worked at an animal lab and I really liked dissecting.” This student may have been an extreme, but the sentiment underlining the comment is surprisingly representative of the premedical mindset – we are more driven by the process and the tools than people. Surgery is a very popular specialty among premeds. And at the end of medical school, the list of students who join the ranks of primary care is short, and the list of those entering care for the underserved, even shorter. I do not mean to elevate primary care or care for the underserved above all other specialties. I simply mean that the sickest and the poorest will pay for our moral wandering.

I’m not sure what can be done about this at a systemic level, or, for that matter, whether something can be done (largely because not everybody agrees this is something that needs addressing). For now, it will be the fight of individual students and doctors making the conscious choice for presence, and against what I call the ‘elevator mindset.’ Medicine is not an elevator that gets us somewhere; the end of medicine is embodied precisely in the stranger we so often ignore on our way to false goals. Christ’s call to ‘love your neighbor’ has never been so needed.

-jds

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3 thoughts on “Reflection on Presence: Part 2”

  1. It looks like one of the problems that you are really honing in on is the problem of the bureaucratization of medicine. This, of course, has a lot to do with the metaphors of mechanization and glorification of efficiency that has characterized capitalism ever since the Industrial Revolution. The question, of course, is that there ARE quite a few benefits to bureaucratization — i.e. it does help correct the abuses of pre-modern societies in which things were very status-driven. It seems as if any real progress on how one might be able to preserve the benefits of bureaucracy while also the benefits of the way of life it superceded might have to do some philosophical reflection on how one might go about judging the goodness of various norms and institutions within medicine. Could maybe revisiting thinkers like Max Weber and his critics be of help? (http://www.britannica.com/EBchecked/topic/84999/bureaucracy)

  2. Some more thoughts: This is a problem that parallels the problem of training professors in higher education. The original conviction of the German founders of the research university was that researchers made the best teachers — which was why they began to insist that university professors also conduct research in addition to teaching. At the same time, however, professionalization of research began to put the goal of pursuing research at odds with the goal of teaching. PhD programs do an excellent job of teaching grad students how to jump through the hoops and climb the ladders of the world of academic research, but how good of a job do they do in preparing grad students to really teach? You can see this complaint in debates over the tenure system as well: it seems that no matter how good a teacher you are, you can’t get tenure unless you’re publishing like a fiend, which often stands at odds with one’s teaching career. (Add this to the fact that the goal of research was originally to enhance culture and that academic research now has a marginal effect on what actually happens in the rest of culture, and we have a real mess in our hands.) At what point does professionalization actually hurt being able to be good professional?

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