On Compassion in Medicine

I’ve spent a lot of time thinking about what it looks like to be a Christian doctor. At first, I thought the answer was pretty simple: excel at what you do (for God’s glory of course), be nice, and be ethical. But, to be honest, that doesn’t look too different from the world’s view of what a good doctor is either. I’ve met a lot of doctors who fulfill these criteria, but when I look at them, I don’t see Jesus.

About two months ago, I started reading through the gospel of Mark. I’m pretty slow with my Bible reading, so I’m not even finished with it yet. That’s beside the point though. I came across a moment in the first chapter that really struck me. The passage reads,

40 And a leper came to him, and kneeling said to him, “If you will, you can make me clean.” 41 Moved with pity, he stretched out his hand and touched him and said to him, ”I will; be clean.” 42 And immediately the leprosy left him, and he was made clean. (Mark 1:40-42)

There’s a lot to unpack in this passage, but my favorite part is the phrase, “Moved with pity.” As a Classics major, I can’t help delving into the Greek a little here. The participle used here references Jesus’ “splagnon” or guts. Basically, Jesus is so affected, that he has a physical reaction to this man’s suffering. This isn’t some case of Jesus saying, “Oh you poor dear, let me kiss it and make it better.” This is God himself, looking at a suffering human and allowing himself to be affected by it. The thing that struck me about this was that Jesus didn’t have to be moved with pity. It would have been perfectly possible for Jesus acknowledge that the man was suffering and to heal him without a personal reaction.

The first thing that this made me think about was the idea of professional distance. I’m not even in medical school yet, so I don’t have a first-hand knowledge of this, but I’ve heard plenty of physicians talk about the need for professional distance. You experience so much suffering as a physician that you have to hold yourself at arm’s length so that you’re not overwhelmed by it. Only then can you be objective and give the patient the highest level of care, and of course, if you allow yourself to get too involved, you can lose your authority in the exam room.

In some ways, this view makes sense to me. Suffering is tough, and you don’t want to be overwhelmed by it. But in Jesus, I see something totally different. I see someone surrounding himself with crowds of sick people, healing them and casting out demons. I see someone who gets to know those he heals. When the bleeding woman in the crowd touches Jesus and is healed in Mark 5, he stops the entire crows so that he can know who it is he healed. He refuses to allow this woman to remain anonymous. I’m borrowing heavily from another author with this idea (whose name I can’t remember), but Jesus could have laid down a blanket healing for everyone in the crowd. But he didn’t, because the identity and the personal suffering of each person he healed mattered to him.

So this is how my thoughts on what a Christian doctor is have evolved. Yes, Christian doctors should excel at what they do. And I sure hope that they have high integrity. But what sets them apart is that Christian doctors embrace human suffering as Christ did. They allow their “splagnon” to be affected at a leper’s suffering. They are willing to sit alongside a patient and share in her suffering rather than stand aloof.

What Is Health for?

Hi everyone,

I’m Calvin. This post is supposed to be an introduction of sorts, so I’ll start with some stuff about me. I’m tall, I’m half-indian, I’m awful at dancing, I’m a recovering premed, I’m a southerner at heart, and I’m currently siting at my kitchen table eating carrots. Basically, I’m a lot of stuff. The most important thing about me, though, is that I’m trying to follow Jesus, even if I’m pretty bad at it.

But for a more serious introduction, I’m the 4th of 5 kids in a family of all homeschooled children. I graduated from Princeton in 2015 with a degree in Classics, and I now live in inner city Chicago, working at a low-income health center (the same one Daniel used to work at.) I’m also trying to go to medical school.

I love the places where faith and medicine interact. As I’ve spent 4 years preparing for med school, I’ve seen more and more ways that medicine is broken. As I’ve grown in my faith though, I’ve seen so many ways in which Christ is the perfect answer to that brokenness. There are other times when I get frustrated because I don’t see how the problems can be fixed. But then I remember that Jesus is returning and that we’ll eventually have a neverending party with the king of all glory. That makes me feel a lot better. There are a couple other topics you may hear me write about: poverty, education, mental health, and sexual assault are all things I care deeply about.

One of the main reasons I’m writing for this blog is that I love to ask why. I want to know why we do things a certain way, why we say what we say, and especially, why we want what we want.

In fact, while I’m sitting here at my kitchen table, writing this blog post and eating my baby carrots, I have a sinus infection. I find that pretty annoying. My ears have a constant crackling noise like someone is unwrapping a twinkie right next to them, my head feels like someone is blowing up a balloon inside it, and my teeth feel like someone is beating them from behind with one of those carrots. As I’m sure you understand, I want to get better. I want to be healthy!

But, because I can’t stop myself from asking questions, a little voice in the back of my head says to me “Why do you want to be healthy? What is health even for?” Shoot. That one made me think. But I have what I think is a pretty good answer: I want to be healthy because then I don’t have to experience this pain and discomfort which kind of sucks.

Then God puts a passage of scripture in my mind to remind me of my own selfishness.

“Not only that, but we rejoice in our sufferings, knowing that suffering produces endurance, and endurance produces character, and character produces hope.” Romans 5:3-4

God tells me to rejoice in my suffering, not to lie here moaning about my pain and wishing it would end. God may use my suffering to build my character. Maybe he’ll use my illness to bring me in contact with a doctor who could be opened to Christ by my love for faith and medicine. Who knows? But here I am, shortsightedly wishing that my teeth didn’t hurt.

All the more, while God may use my suffering for good, I’m not sitting here thinking of how I could use my health for him. I’m not sitting here saying “God make me better so that I can serve you better.” I’m allowing health to become and end, rather than God himself. That my friends, is called the idolatry of health. It’s so easy to fall into, as my overly-pressurized sinus passages will attest to.

In any case, I hope this post made you think a little bit, laugh a little bit, or better yet ask God how he can use your health or lack of health.

Recovering the ‘Relationship’ in the ‘Physician-Patient Relationship’

It is no longer possible to call the physician-patient relationship a ‘relationship.’ It’s no surprise, given that other forms of human relationships, including those between spouses, employer and employee, and parent and child, have become mere battlegrounds for the assertion of political rights – a grotesque dance in which both parties are more obsessed with protecting oneself or not stepping on the other’s toes, and less on actually creating beautiful movements. Such a dance, in the end, is not a dance at all.

The lack of a substantive conception of the physician-patient relationship in medicine is nowhere more apparent than in the paternalism vs autonomy debate. The dichotomy spawns from a curious and particular narration of medical history, in which medicine ‘in the old days’ is seen as an intrusive, colonial force that has no regard for the moral agency of patients, and in which the ‘new’ medicine moves towards a better model that simultaneously prioritizes patient choice and opinion and restrains physician authority. In this narration (and this is the implication of the dichotomy), the patient at best is a glorified bag of rights, whose interests must be protected from the ever-encroaching violations of medical authority. Physicians, likewise, must ensure they make no mistakes, or at least, err on the side of giving the patients what they ask, lest they get sued or, even worse, score poorly on patient “satisfaction” ratings. Physician and patient are pitted against each other, and the ‘relationship’ is a total misnomer for what has functionally become a battlefield in which the patient must always rise victorious. 

Certainly, this narration was useful, for events in medical history have given us very good reasons to be wary of authority. The Nazis used theirs to justify a perverted and insatiable thirst for scientific knowledge, and conducted unthinkable experiments on millions of Jews. The Americans – the self-proclaimed purveyors of democracy – were not exempt from similar sins. For a period of time, American physicians conducted systematic sterilization of those we considered undesirable, and we used science to justify why they were undesirable, using such vague and euphemistic terms as ‘imbecilic’ or ‘aggressive.’ In the infamous Tuskegee experiments, physicians (who were white) infected poor black farmers with syphilis without their knowledge in order to follow the disease progress, and reinforced a continuing legacy that has left black Americans with a gnawing, subconscious distrust of medical authority. The abuse, and misuse, of authority happens even today – sexual misconduct and discriminatory treatment of the homeless are a few of its faces. Given all of this, it is undeniable that patients need very important protections from their physicians, and laws such as HIPAA (which protects every patient’s privacy) should be lauded as examples of real progress. 

But we cannot stop there. Even if the language of protection and rights was necessary to minimize the possibility of the abuse of power, the medical profession cannot let that language be the sole resource for how we enter into relationships with patients, for this is a very impoverished view of what that relationship may be. If we discount all forms of authority – pointing out where it exists and attempting to expunge all of its vestiges – we will find ourselves living a delusion and practicing a medicine that honors the humanity of neither the patient nor the physician. I believe, rather, that we should interpret medical history differently: the lesson of Nazism, Tuskegee, and other instances of the abuse of medical authority, is not that medical authority is evil and to be shunned, but that authority must be housed in a proper covenant between physician and physician and physician and patient.

For one, asking physicians to totally relinquish their authority is simply impossible; whether we like it or not, physicians are authority figures. 

Take the Flexner Report (1910) and the subsequent birth of modern American medicine. [The Flexner Report is, perhaps, one of the most important documents in the history of modern medicine, and not just in the United States, given its repercussions. Prior to the Report, American medicine was a chaotic melange of quackery and medical science – there was no national standardization of physician training and licensure, medical schools did not collaborate with hospitals, and anybody who took courses at a self-proclaimed ‘medical school’ could feign doctorhood. The Report designated Johns Hopkins Medical School (then one of the very few medical schools that combined scientific research, bedside clinical teaching, and patient care at an affiliated hospital) as the example for all American medical schools to follow, and caused the closure of all schools that failed to conform.] Why did the Carnegie Foundation, the sponsor of the Report and one of the largest American philanthropic organizations, commission a study of the medical profession rather than any other? Interestingly, the Foundation sponsored the report as a response to the seeming declining moral and cultural power of the Christian church in American towns and cities and the speculated rise in such power among physicians. Instead of turning to their churches and clergy, the Foundation believed, Americans would now turn to their physicians for guidance in birth, life, and death. All hail the new priesthood of medical science.

This speculation, it turns out, was spot on, for medicine holds such great sway in the minds and lives of Americans today that it would not be amiss call medicine the new religion. Without a positive conception of the meaningful life oriented around true goods, health, long life, and the prospect of controlling one’s destiny have become the idols at whose feet Americans lay a heavy sacrifice. Medicine can create life when we want and it can destroy it when we want; medicine can better our mood and dampen our sadness; medicine can define (in its own language) what it means to be well and not well, normal and not normal, human and not human. Here, the physician, like the Levites of old, stand as mediators between the emptied soul, scrambling to grasp whatever it can to fill its inner void, and the god that cannot deliver on its grand promises. So we see that, no matter how much physicians would shun the title, they are moral authorities, and giving the patient what they seek is not a “neutral” act, but a morally charged one, establishing a certain view of happiness, of meaning, and of purpose, centered on the unrestrained and untamed desires of the human heart.

Physicians nowadays would largely deny the above (namely that they are moral authorities whether they like it or not), but even then, other forms of authority subsist in medicine. Indeed, they must, for coherent collective action is impossible unless there is an authority structure that ensures, or at least encourages, the alignment of individual action with the collective vision. In the medical profession, the absence of moral dialogue or consensus, stemming from the refusal to engage medicine as a moral practice, simply leads to the establishment of technical expertise as the new basis and language for authority. Since we cannot agree on the ‘why’ questions, we have largely resigned to answering only the ‘how’ questions; medicine has no purpose or limited end, let’s use it for everything, and let’s just focus on how to do those things in the most efficient and most profitable manner. This was Weber’s great insight – the bureaucratizing force that shapes all human institutions in the secular age. The end result is a profound ‘disenchantment,’ in which spiritual concepts such as the birth (or death and killing) of a child, the passing of the elderly, and even human emotions lose their glow of mystery and become mere procedures to be optimized. Technical prowess, optimization, and efficiency is the language of a profession fearful of engaging the moral nature of its own practice.

One can see how, in this impoverished environment, the ‘transaction’ model would emerge as an attractive model for physician-patient interactions. Patients request a particular service, and physicians, like a dispensing machine, simply provide that service, no questions asked. It is, supposedly, the morally ‘neutral’ default that resolves the paternalism/autonomy tension. But if what I’ve said so far is true, this is more like a delusional solution to a false problem. In fact, one might interpret the prevalence of physician burn-out and patient dissatisfaction and mistrust (and malpractice suit rates) as the symptoms of a dehumanizing transactionalism. If so, a more positive vision for relationships is urgently needed – a vision that does not merely fill in the gaps in a rights-based, transactional framework, but one that reimagines entirely what it means for an authority figure to serve, guide, and be present with, those who are suffering from illness. As I’ve suggested before, this might involve recovering the language of covenant in medicine.

The question, then, is how this covenant can be sustained, for the acknowledgement of authority comes with great responsibility to steward that authority and use it for good, not for evil. Already, we see that the task of medical education is enormous, and must rise above simply imparting technical knowledge – it must, no less, produce good physicians. 

The problem of medical education, and how we can impart a vision for the ‘good physician’ to successive generations, I will address in the second part to this post (to come later).

Learning How to be Human

I had my first interaction with a patient last week (I’ll call him John). He was a reticent and withdrawn teenager, who, when I first approached, was reclining on an arm chair with earbuds plugged, staring off into a corner of the sterile room. His grandfather, who had brought John to the hospital, looked equally disinterested. My task was to interview him, and my supervising physician would evaluate me on my interviewing skills – whether I asked the right questions, how well I was able to solicit answers, etc. I knew right away as I saw John that it was not going to be easy.

And it wasn’t. It felt like wading across a wide, swampy moat – a moat that John and his grandfather had dug even before I spoke a single word. John was at the hospital for a routine service, and as far as they were concerned, I was a disturber of their relative peace. As I introduced myself and explained to them why I wanted to talk to them, John’s grandfather sternly warned that our interaction better not last more than they needed to stay at the hospital for John’s visit. “No more than thirty minutes,” he said.

I began asking John questions about his illness, and the effect it’s had on his life. Yale’s patient interview curriculum – which prides itself in its radically patient-centered approach – had promised me that if I ask an open-ended question and shut up for 3 seconds, the patient would fill the silence with a lengthy response.  John, though, met all of my questions with a terse response and a sideways glance.

“How has having [your condition] been for you?”

“Just…normal. It’s just normal.”

After about 15 minutes, I started to ask about his family. I learned that he had previously lived with his mother, and visited his maternal grandmother every week (the grandfather he was with was his paternal grandfather). Nowadays, though, he lived with solely his grandmother. I asked him if he could tell me why. John’s grandfather, who had been listening the whole time, stepped in. “That’s getting personal.” I had crossed a boundary.

I gave up. There was no use in pursuing my agenda anymore, and as I let go, what surfaced was an apology. I told them that I was a first year medical student – naive, blundering, just learning to crawl in this medical profession; that I am sorry if I offended them. I was told by my teachers that I needed to treat patients as whole, and should ask about the lives they led beyond the hospital; I was just trying to understand who they were…

I asked John about the music he was listening to. He liked dubstep and electronic dance music.

“Dude, so you like beatdrops?”

And for the first time, he smiled.

We went on to chat about his schoolwork, and how he had starved himself of video games for 6 months for the sake of his grades. He had straight A’s. More smiles.

Donald Berwick, in his address to the graduating class of 2010 at Yale Medical School, noted that a good physician is not the one who readily dons the white coat (with its accompanying pedestal and power) but the one who readily gives it up.

Congratulations on your achievement today. Feel proud. You ought to. When you put on your white coat, my dear friends, you become a doctor.

But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul.

I wrote before about the phenomenon of ‘the bridge’ in medicine – that to become a doctor is to enter a world from which there is no returning. The irony is that becoming a healer precisely requires this return. I must learn, no less, to become human again.

The finding is in the giving-up… It is a principle that harkens me to the poetry and truth of Christ’s paradox: “Whosoever wants to save his life will lose it; and whoever loses his life for me shall gain eternal life.” So I gladly seek the place in which I become nothing – the place where I unmask all that I’ve toiled to put on to find that I am, in the end, simply Christ’s beloved. And in that place of nothing (which is the place of everything) I gain the vision to see John for as he really is: not as “a difficult patient,” but as fellow man, deserving of love.

This is the place where medicine transforms from a “giving to” or “fixing,” to “walking with.” It is where true ministry and healing is possible.

Medicine and Seeing

Lord, give me eyes to see…

I’ve been praying this prayer a lot recently, in the first few weeks of medical school. Sight is a gift. To see our lives, the lives of others, and the events of our world in the lens of truth and love – that spirit is something we cannot conjure up on our own. The God of truth and love must gift it to us.

Each morning, I wrestle for this sight, as Jacob had wrestled God for His blessing. Jacob had spent his entire life crafting his own blessing. There is the time when he steals his brother’s birthright with a well-timed meal. And the time he tricks his blind father into blessing him instead of Esau with a clever scheme. He amasses a vast amount of wealth as Laban’s shepherd, taking the strong of the flock for himself, and leaving his uncle the weak ones. Jacob then runs away with Laban’s two daughters and his massive herd to begin his own life – to look for his own paradise. That is the picture of Jacob before his encounter with God: he is always running.

He is still on the run when suddenly he is forced to account for his life. Esau, his long-estranged brother, is said to be approaching from the far side of the wilderness, likely to kill him. Jacob ‘runs’ one more time, trying to appease his brother with a series of gifts, and ultimately, dividing his camp into two so that if one is attacked, he is left with the other. As he sends his camps off, he is left by himself (Gen 32:24) – his first time in true solitude. Desperate, cornered, on the verge of calamity, and finally alone, he does what perhaps God had been trying to get him to do all along. He simply asks. “I will not let you go unless you bless me.”

“I will not let you go unless you bless me!” That is a holy prayer.

Lord, give me eyes to see…

‘Education’ is a misnomer for what happens in the four years of medical school. Becoming a doctor is about more than just the accumulation of medical knowledge. Medical school is assimilation – the inculcation of a set of values which is no less cultural because it’s scientific. Medical school is a foreign country, complete with its own language, and therefore, its own way of seeing.

Before anatomy class began, our professor told us his philosophy for teaching anatomy, which was to help us ‘see what doctors see.’ He told us that as we open our donors’ bodies and delve beneath their skin into their viscera, we will look, but not see, because we do not yet have the framework to make sense of what is in front of us. What is this intricate mesh of meat, fat, and bone? I do not know, and so the world of the body is still fresh. It is still sacred.

But when will that eternal light dim?

There’s a passage in Annie Dillard’s ‘Pilgrim at Tinker Creek’ that I often reread. Apparently, when physicians first discovered how to perform safe cataracts operations, patients who had been blind all their lives were suddenly able to see. Having never associated words and meaning to visual stimuli, they saw the world differently than the already-sighted. They didn’t see chairs, tables, books, food, shadow, form, or size – they saw patches of light and dark, blobs of color, brushes of unencumbered, freeform marks.

“A twenty-two-old girl was dazzled by the world’s brightness and kept her eyes shut for two weeks. When at the end of that time she opened her eyes again, she did not recognize the objects, but, ‘the more she now directed her gaze upon everything about her, the more it could be seen how an expression of gratification and astonishment overspread her features; she repeatedly exclaimed: ‘Oh God! How beautiful!’”

It will be a tragic day when I stop exclaiming ‘Oh God! How beautiful!’ When, instead of the intricate mesh, I only speak of mediastinum, costal cartilage, inferior vena cava, ad infinitum…the babble (Babel?) of those of who know, but do not see.

Not long after that anatomy class, Dr. Lisa Sanders, who had started the New York Times column that inspired House, M.D., led a session for first year students on the topic of observation. ‘Writing is observing,’ she said, ‘and you must practice writing in order to keep observing.’ She then showed us a picture of a scene in the wards, in which a medical student was leaning over a patient to observe something on her shoulder. Dr. Sanders asked our class, “What do you see? What do you notice about the patient and the student?” Our class spent 5 minutes sharing our observations. We talked about how the patient looked afraid and how the student’s posture seemed to belie a certain eagerness. We noticed emotions and facial expressions, and imagined movements from the stillness of the photograph. At the end of the exercise, Dr. Sander turned to our class and warned, “What you see now, you will no longer be able to see 10 years later. You, still being laymen, notice things I no longer care to notice as a doctor. Medicine is a bridge you cross; there is no turning back, even when you wish so much to be back on the other side.”

And that is why I pray for sight, with Jacob’s desperation. The battle for eternity happens in minutiae, and our souls soar or fall in trivialities we are prone to overlook amidst the comfortable humdrum of our lives. I pray before anatomy class that the God of healing may help me to know wholeness – that the ease with which the blade slits the skin does not dull me to the beauty of embodiment. I pray to see the weight of glory in people I pass by everyday. They are not merely ‘a nurse,’ or ‘a student,’ or ‘the person who takes care of your paperwork’; they are eternal, divine beings – imago dei – whom, as C.S. Lewis says, I’d be tempted to worship if I saw their true glory.

I pray, finally, that the Gospel would remain news. Too many times I let the Gospel become familiar, which also means that it becomes comfortable. It is not. I have to encounter the person of Christ daily and come to terms with its truth, and the demands and costs that truth makes on my life. There is no easy way out. He is calling for me (“Remember your first love!), and it means my death. The scales must daily be taken off from my eyes.

And with this I plunge into this medical world. I will learn its language, but I refuse to let that language define what is real and what is true, for I am afraid to be in a world I can box, devoid of mystery and beauty, where everything I see I can shatter in a thousand classifiable, knowable shards, and piece them back together to fit my convenience. So I worship, pray, and wrestle.

Lord, give me eyes to see…

Then Elisha prayed and said, “O LORD, please open his eyes that he may see.” So the LORD opened the eyes of the young man, and he saw, and behold, the mountain was full of horses and chariots of fire all around Elisha.” (2 Kings 6:17)

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The passage on ‘Seeing’ from Dillard’s ‘Pilgrim at Tinker Creek,’ which I quote from, and which I highly recommend, can be found here: http://dcrit.sva.edu/wp-content/uploads/1974/01/Seeing.pdf

Physicians: too busy for patient care?

David Foster Wallace opened up his rather memorable 2005 commencement speech at Kenyon with the following story:

Two young fish are swimming along and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys. How’s the water?”
The two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

That is, the reality and culture in which we’re immersed can be quite hidden to us if we don’t continuously work to remind ourselves to stay aware.

There are parts of medical culture that I’ve come to take for granted; narratives I’ve rehearsed and excuses I automatically give for why things are the way they are, even when they seem at odds of serving the patient’s good.

It’s unsurprising that pride underlies a lot of these non-ideal realities, but being aware of how exactly we’ve let ourselves be gradually puffed up is harder because this is our reality.

A typical day in the hospital starts with pre-rounding, i.e. seeing the patient for 2-3 minutes in the morning to see if anything “acute” has happened overnight (i.e. is it something worth mentioning to the attending?) and then spending the rest of the hour pulling up “objective data” (i.e. labs, vitals, imaging) to present during rounds. In rounds, depending on the attending, you might sit in one room and discuss the patients without ever going to see them; you’ll maybe spend 10 seconds talking about the patients themselves; much longer presenting the objective data and discussing the consults you’re going to call and tests you’re going to run that day. Then the rest of the day you’re going to run around following through on these, fielding phone calls, checking the EMR (electronic medical record) often for updated information, and at the end of the day, what you’ve taken care of is more the data about a patient rather than the patient himself.

And this is in the more “humanistic” parts of medicine – during my surgical rotations, how often did we (half-)joke that patient “looks good from door” and write from day-to-day: “ambulating, urinating without catheter, positive for bowel movements,” as if that were the sum of the patients?

We grumble to one another about our lack of sleep and that there’s never enough time to take care of things in the hospital; we get impatient when a patient has a “complaint” (literally, that’s what the medical jargon calls it) or has something to tell us that “doesn’t change medical management.”

Inwardly we ask, “Why are you wasting my precious time?” right before we spend 20, 30 minutes chatting to our peers, holed up in the residents’ room. We always have more than enough time if another physician wants to talk to us about what recommendations they may have or even if a more senior physician wants to pontificate on some random tangent; we try hard not to give in to the urge to check our watches or restlessly tap our feet when a family member or a patient stops us and has something “important” to tell us. “Sorry, we have to go,” we say as soon as they pause to take a breath.

We make huge life-altering decisions within the confines of the physicians’ room and then ask the nurse to let the patient know as we scurry away to take care of something else.

I get it, we’re sleep-deprived and busy, but are we so busy we’ve forgotten to take care of our patients? Or are we justifying ourselves out of a misguided sense of self-importance ?

Anyway, I’m part of the problem, and recently I’ve been convicted, as James has some pretty harsh words about the sin of partiality (with some insertions of my own):

Show no partiality as you hold the faith in our Lord Jesus Christ, the Lord of glory. For if a man wearing a [white coat] comes into your assembly, and a [malodorous homeless patient in disheveled clothing] also comes in, and if you pay attention to the [one in the white coat] and say, “You sit here in a good place,” while you say to the poor man, “You stand over there,” or, “Sit down at my feet,” have you not then made distinctions among yourselves and become judges with evil thoughts? Listen, my beloved brothers, has not God chosen those who are poor in the world to be rich in faith and heirs of the kingdom, which he has promised to those who love him…

If you really fulfill the royal law according to the Scripture, “You shall love your neighbor as yourself,” you are doing well. But if you show partiality, you are committing sin and are convicted by the law as transgressors.

And elsewhere in the Bible we see Jesus going out of his way to bless the unimportant, those that wouldn’t have necessarily “changed his ministry” or in any way made him “more efficient” in proving his divinity.

Then children were brought to him that he might lay his hands on them and pray. The disciples rebuked the people, but Jesus said, “Let the little children come to me and do not hinder them, for to such belongs the kingdom of heaven.” And he laid his hands on them and went away.

So now that I’m aware of parts of the medical “water” — how, then, shall we live?

What Medicine Cannot Give…

Then Peter said, ‘Silver or gold I do not have, but what I do have I give you. In the name of Jesus Christ of Nazareth, walk.’

Last week, I took a seminar on medical ethics, held at Princeton through the Witherspoon Institute. The seminar explored many different topics, but ultimately converged on a central theme: physicians must know what medicine is for.

Medical imperialism is real. New technologies and advancements have given us the tools to achieve outcomes that were unimaginable before (think IVF, cosmetic surgeries, transplants, etc). In light of these technologies, the role of the physician has fundamentally changed.  Physicians are now expected to take on the roles of reproductive counselors, beauticians, behavioral modifiers, and scores of others that have varying degrees of relevance to medicine, traditionally defined. We are watching, quite spectacularly, a new Manifest Destiny unfold.

So here’s the million dollar question: is this a good thing? Should we increase in medical powers as harbingers of a brighter future? Or do we have reasons to resist a redefining of medicine?

It is important to raise the question of definitions, and relatedly, the question of limits, because merely accepting the new possibilities would inevitably lead to a sort of consumerism.  We are already seeing this. In parts of healthcare, physicians act as dispensing machines of healthcare services – the supplier that simply meets demand. And consumerism, we know, is a terrible substitute for the physician-patient relationship.

Secondly, without proper limits, medicine can become a bait-and-switch. This is especially true when patients seek what medicine ultimately cannot give. The woman who seeks plastic surgery will find that her disease was not her appearance but her insecurity. The man who demands aggressive end-of-life treatments will find that delaying death is fruitless. Medicine cannot give life, fulfillment, or love. Sometimes, it cannot even give health (the thing that medicine is ostensibly for!).

The passage in Acts is one I’ll remember in my journey through medicine. Here, Peter approaches a beggar sitting at the temple gates; the beggar is lame, and has resigned himself to asking passersby for money. Of course, money is not really what this beggar needs, and Peter tells him so (sidebar: can patient autonomy account for this kind of interaction?). Peter, rather, gives the beggar what the beggar himself has lost the ability to hope for: the restoration of his being.

That, I think, is what Christian physicians can do well – to have in mind both what medicine cannot do and what patients truly need. Both go hand in hand. In the world of ever-increasing possibilities and amidst a medical culture without a vision or language to challenge its expansion, Christian physicians can be witnesses to the Kingdom by staying oriented to the true goods.

Should We Pray With Patients?

The patient was abruptly, unexpectedly, and neurologically devastated, leaving his family stunned and grief stricken.  There was little else for the ICU team to offer, even as we worked to do everything physiologically possible to sustain life.  It was late at night and as we stood in the room listening to beeping monitors and the running motors of IV pumps, the family mentioned in passing that many people were praying for him.  So I asked them two simple questions: Are you Christian? Would you like me to pray for you?  They answered yes to both.  I led them in a short prayer, expressing no more in terms of medical prognosis or aspirations for therapy than had already been offered, but also asking for strength, wisdom, and a clearer understanding and experience with God himself.  The family was marginally but visibly relieved and calmed by it, and we continued on with the grueling task of caring for the patient.

As anticipated, the patient passed away several days later.  After the family left, their nurse told me, “They could not stop talking about that prayer.  They said that of the dozens of physicians they have interacted with over many years, not a single one ever offered to pray with them.  It meant a lot.”

Modern healthcare is conflicted about how to approach faith and illness.  On the one hand, rising pressure to improve patient satisfaction must recognize the importance of faith in the lives of patients; in one small family practice study, 48% percent of patients wanted a physician to pray with them (even though 68% never had a physician discuss religious beliefs with them).   On the other hand, the secularization and humanism-ization of medicine can use the ethical mandate to respect patient autonomy as an excuse not to engage in matters that could be controversial (such as faith).  Fear of “abuse of paternalistic power” in the physician-patient relationship or fear of invoking religious ritual and methodologies that are virtually impossible to hypothesis-test can create a “chilling effect” on the inquiry and expression of religious belief by healthcare workers even when no hostility or indifference is there.  It is as if medical practitioners find it hard to believe that faith not only exists, but that it could possibly matter more to patients than the field of medical therapeutics itself.

The earliest practitioners of medicine were clergy members.  In virtually every culture, ministers of medicine began as… well, ministers.  After all, what can be a more compelling reason to drive us to our knees than helplessness in the face of suffering?  Though modern medicine can explain the physiology of how we decay and die in excruciating detail, it is certainly not equipped to answer the question of why we do.  This observation alone should explain why questions of faith contend to occupy the center of a patient’s attention and not simply the periphery.

The next time you are in a small group or a prayer gathering, try to count how many times health-related concerns come up for prayer.  Illness afflicts our minds, hearts, and souls as readily as our bodies.  Healthcare workers are compelled to take hours of training in cultural sensitivity, mindfulness, and meditation; shouldn’t we be similarly compelled to attain and encourage proficiency in spiritual need assessment, willing to offer prayer when requested instead of retreating in indifference?  Shouldn’t this be true in all the “helping professions”?

Why You Must Die, Before You Die

I’ve been thinking about death some – how it happens, what people think.

My clinic recently faced tragedy. Dr. Jerry Umanos was shot and killed at a hospital in Kabul, Afghanistan.  He had worked for the past 25 years as pediatrician at Lawndale Christian Health Center (located in inner-city Chicago), and for the past 10 years, had been volunteering part of his time training pediatric residents in Kabul. He had gone, against all warning,  to seek the poorest of the poor, and the neediest of the needy. LCHC saw him last this past January, when he gave a testimony before our whole staff about his work, and explained why he was going back once again to that war-torn land.

Keep Dr. Umanos in mind for a moment and consider end-of-life care in America. Most Americans will die a slow death, maybe brought on by cancer, maybe brought on by organ failure. There are two options when you are faced with a diagnosis that signals the end: aggressive (often experimental) treatment that probably won’t work and if it does, will leave you barely alive; or hospice, where physicians ease the pain for those who’ve already accepted death (hospice can occur either at home or in hospital).  According to articles like this one, more Americans are opting for the former, and saving the latter for when the former has failed. Interestingly, Christians (or those who identify as more religious) are even more likely to pursue aggressive end-of-life treatments. Simply put, our healthcare system (and our society) is teeming with people eeking out nanodrops of life with every last effort and dollar. We are hanging onto life with the very tip of our nails.

I hope the juxtaposition is as jarring to you as it as to me. On one hand is a man who shuns his life (perhaps even foolishly so) to serve in Afghanistan, and on the other hand are people (especially religious people) trying to live some more.

Obviously, end-of-life situations are incredibly complex, and it’s difficult to know what to do in the mire of emotions, tensions, and false hopes. I don’t pretend to know how to navigate through those situations, so this article won’t be about the ethics of end-of-life care. Instead, I want to point out how much the death of Dr. Umanos and the deaths of others in the American healthcare system reveal a sad truth about Americans: we are not ready to die.

This is bad news, at least for Christians, because death is one of the biggest things Christ stresses to his fledgling disciples: ‘You must pick up your cross daily and follow me’; ‘Whoever wants to save their life will lose it; whoever loses his life for me will find it.’ If they didn’t understand when he was speaking this to them in person, then surely they understood when their Lord hung before them on the cross, shamefully bloodied and scarred.

Paul eventually reiterates this theme in his epistles, telling the Philippian church, for example, that ‘to die is gain, and to live is Christ. If I am to go on living in the body, this will mean fruitful labor for me. Yet what shall I choose? I do not know!’ Only a man who dies daily could utter such words.

I think what Jesus (and Paul) was trying to point out is that life is a gift, not an ultimate good that should be pursued at all costs. And of course, this goes against everything in the dominant narrative in America. Lacking greater purpose, we live to feel alive: to travel and see the world, to engorge food with our bodies and take pictures of them on our phones, to drink and be merry with loud music beating in our ears, to pursue power and influence, to be intoxicated in love. I am not saying we should not enjoy these things. I am only saying that it becomes dangerous when these things mark life itself – when we jump from thrill to thrill seeking ways to adorn an otherwise vapid and listless trajectory.

If we do not die now, it will be too late when death really comes. Death should catch us in the act of dying, not in the act of living. Christ’s call to the cross is a very serious charge, and we would do well to pray over His words daily and to search the ways He is urging us to die today.

What is healing?

//Because I have a short attention span, I assume others do, too, so I try to use a different color text for “main ideas.”

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It’s probably a bit strange that after four years of medical school, I’m not sure what “healing” actually means, or that medicine (as a field) is even about healing. Treating a disease or pathology is not the same as healing a person. The absence of disease is…well, the absence of disease, not necessarily health. We don’t cure cancer– we usually just cut off the offending organ or treat it with radiation/chemo and hope it doesn’t come back elsewhere. Many, if not most, diseases can’t be cured (think of chronic conditions like COPD, heart failure, schizophrenia, diabetes, etc.) – even with the best medical treatments, their effects can only be slowed or minimized, though they all eventually result in the inevitable progression of disease. Even if the best medicine can “cure,” I would venture to say that only the mildest of infections can probably be “cured” completely, and that “curing” just means returning you to baseline.

Which makes it that much more astounding that Jesus healed the sick and in turn commanded his disciples in Matthew 10:8 to heal the sick.

What does it mean that He healed, that we are supposed to heal and be healers?

Though he was addressing seminary students in the excerpts below, Paul Tillich’s thoughts have also been helpful for me as a soon-to-be physician, as his reflections on health and sickness appropriately grasp the comprehensiveness and complexity inherent in disease and health.

1) Health is about unity – the wholeness and integration of body, mind, and spirit – and shalom (this comprehensive flourishing) is the ideal. Let’s not mistake the absence of disease for health, because its absence could just mean we’ve discarded the parts of us that have the potential for disease, which are also the parts of us that have the greatest potential for life. I see this as particularly true in mental health, when the best treatment can get rid of the problem without having addressed the root of the issue (e.g. antidepressants that make you not depressed, but is to the point to blunt emotions so that one is non-suicidal, or to work with the patient to understand how to deal with pain in a meaningful way and still find joy?)

Health is not the lack of divergent trends in our bodily or mental or spiritual life, but the power to keep them united. And healing is the act of reuniting them after the disruption of their unity. “Heal the sick” means — help them to regain their lost unity without depriving them of their abundance, without throwing them into a poverty of life perhaps by their own consent.

2) People in medicine often talk about how increasing specialization (to keep up with unmanageable amounts of information) creates “siloes” that compartmentalize providers into only being able to treat very specific problems.

Take, for example, diabetes, one of the most common problems in the US. If you have diabetes, you probably have an endocrinologist to manage your insulin schedule, an ophthalmologist to check out potential diabetic retinopathy, a nephrologist to make sure your kidneys aren’t failing, and a cardiologist and/or neurologist if you’ve experienced any heart attacks or strokes as a result of that diabetes. And a PCP (primary care provider) to coordinate all of that. Our very training implies that we are to stay within our areas of “expertise,” and that expertise is limited to only certain organs, which in turn can cause us to reduce our patients to organs.

But health means wholeness, and shalom is about individuals, communities, and systems – even (or especially) in medicine. And that ultimately sickness has a spiritual component in that all illness is a reflection of sin, or separation (maybe the sin of nature, but sin nonetheless.) That is why in the stories of healing in the Word, it is never just an individual’s physical healing alone, but a restoration to one’s community (as in Matthew 8, when the fever leaves, she prepares a meal for others) and spiritual healing (e.g. in Luke 5, when Jesus heals the paralytic, spiritual healing (“your sins are forgiven”) is closely linked with physical healing (“rise and walk”), and the response of the paralytic is not just physical (“he rose up before them and picked up what he had been lying on and went home,”) but also notably spiritual (“he went home glorifying God”)).

And you have learned that disease that seems bodily may be mental at root, and that a disease that seems individual may be social at the same time, and that you cannot heal individuals without liberating them from the social demons that have contributed to their sickness. Beyond this, you may have become aware of the fact that both physical and mental, individual and social, illness is a consequence of the estrangement of man’s spirit from the divine Spirit, and that no sickness can be healed nor any demon cast out without the reunion of the human spirit with the divine Spirit.

3) Though health and healing are huge concepts, ones that I still don’t fully understand, this at least is true: we know that our God is Jehovah-Rophi, the Lord who heals (Exodus 15:26), and that the real illness and diseases that we ought to fear (i.e. not the bodily ones) have been borne by Christ, who took them upon Himself.

 You have a glimpse of what can heal ultimately, of him in Whom God made manifest His power over demons and disease, of him who represents the healing power that is in the world, and sustains the world and lifts it up to God.