Sunday, June 30, 2019

Teaching English in an anti-democratic culture

Two days ago I led a workshop for teachers on "Making Ethics part of High School and Middle School English Class" at the Bread Loaf School of English in Vermont, as I've done every summer since 2012. (A post about last year's workshop, with links to earlier posts, is here.)

We began from the perception held by the teacher-participants that many of our leaders do not demonstrate democratic values. Not surprisingly, the anti-democratic characteristics that are so prominent in our political culture are showing up in the classroom as self-centeredness, lack of respect for others and intolerance of differences. The teachers believe that our political culture intensifies the self-centeredness that is part of human nature and normal development.

The teachers discussed a wide array of classroom approaches they use to encourage democratic values in their students. These included:

As someone who has never taught at the pre-college level, all of these techniques made sense to me, much as many of the different "schools" of psychotherapy make sense. I believe they share the aim that a participant called "metacognition" - the capacity to step back from our own initial thoughts and emotions to take a wider view of the situation we are engaged with.

Another participant urged teachers to "return to our lofty purpose" of drawing students into the magical world of words - literature and writing - as both a primary aim and as a path towards strengthening democratic values.

The teacher-participants unanimously agreed that literature and writing promote the democratic orientation that American schools seek to strengthen.  Well chosen texts act both as "mirrors" (helping students sharpen their own sense of identity) and "windows"(fostering understanding of others). And learning to write well teaches us to step back from our original thoughts and words to see whether we can back up what we're saying and whether we're saying it in a way our readers will understand.

Over the many years I've spent at the Bread Loaf School of English I've learned from the teachers who are students in the program that the primary objectives they have for their students are to (1) increase skill and engagement with literature and writing and (2) promote development of democratic attitudes, altruism and concern for social justice. 

At its heart, teaching, like medicine, is a calling. Supporting education for all should be one of our first goals as citizens. It's a privilege to be able to work with dedicated teachers like the group I worked with on Friday.

Tuesday, August 7, 2018

The Moral Responsibilities of Pastors and Psychiatrists

A recent New York Times article reports accusations of "inappropriate" sexual behavior on the part of Reverend Bill Hybels. The article describes Hybels as a "superstar pastor" who initiated the megachurch era by founding the Willow Creek Community Church.

In 1985, feeling lost after her divorce, Pat Baranowski felt that God had spoken to her when Reverend Hybels reached out to her, drew her into the church, gave her a job, and ultimately invited her to live with him and his wife and children. She alleges that Reverend Hybels drew her into a relationship that included oral sex. She ultimately ended the relationship, but was plagued with guilt, shame and a feeling that God's servant had betrayed her.

Ms. Baranowski kept her story to herself until other women brought forward allegations of their own. Reverend Hybels vigorously denies all of the allegations, calling them a mix of "misinterpretations" and "outright lies." The church elders investigated the allegations against Reverend Hybels and concluded that they were not believable. But a day after the New York Times article, Reverend Hybels resigned from his leadership role in the church.

The Hybels/Baranowski story illustrates in dramatic fashion the tinder-box nature of pastoral and psychiatric relationships. A vulnerable person feels uniquely understood by a trusted caretaker who is invested with the charisma that comes from being seen as a pastor serving God or a physician serving the healing profession. The pastor or physician receives love, gratitude and idealization. Used skillfully and responsibly, this "transference" can promote healthy development. But as Ms. Baranowski and other members of the Willow Creek congregation allege, the relationship of trust can be exploited, with potentially devastating consequences for the congregant or patient.

As is so often the case, this is a "he said/she said" situation. Reverend Hybels presents himself as a victim, not an exploiter/sinner. There is a continuum of possibilities. At one extreme, he could be the victim of a combination of misunderstandings, fantasies, and malicious accusations. At the other he could be an exploiter who is fully aware of his duplicity and issues denials he knows to be false. In between is a range of misunderstandings and human frailties on the part of all parties to the relationships.

Pastors and psychiatrists have distinctive ethical obligations associated with their roles in society. These obligations go beyond ordinary morality. Whatever religion they follow, pastors present themselves as servants of gods, devoted to the salvation of their congregants. Psychiatrists and other physicians present themselves as servants of medicine, devoted to serving their patients' health and well-being. In return for these commitments, society grants pastors and physicians distinctive forms of respect and privilege.

Whatever the truth is about the Willow Creek Church situation, it's a tragedy. #metoo will see one more example of male exploitation. Some of the faithful Willow Creek congregants will see misunderstanding, maliciousness, or even the devil instigating false accusations. An anthropologist from Mars will not claim certainty about the truth of the situation, but will see it as an inevitable hazard created by our human needs, vulnerabilities and limitations.

(For posts that discuss the power of transference in the pastoral and psychiatric relationships, see here and here.)

Friday, August 3, 2018

The Enduring Wisdom of Franz Ingelfinger

On May 5, 1977, Dr. Franz Ingelfinger, editor of the New England Journal of Medicine, delivered the George W. Gay lecture on medical ethics at Harvard Medical School. I was in full time practice at the time and, alas, was not at the lecture.

Dr. Ingelfinger, one of the world's experts on esophageal cancer, had developed the disease he had taught so many others about. Here's what he tells us with regard to the difficult question of whether to undergo chemotherapy and radiation after surgery:

I received from physician friends throughout the country a barrage of well-intentioned but contradictory advice. As a result, not only I, but my wife, my son and daughter-in-law (both doctors), and other family members became increasingly confused and emotionally distraught. wise physician friend said, "What you need is a doctor." He was telling me to forget the information I already had and the information I was receiving from many quarters, and to seek instead a person who would...tell me what to do, who would in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief."
Yesterday I spoke with a dear friend whose spouse is suffering from a profoundly serious medical condition that calls for complex clinical, psychosocial and financial decisions. My friend reported "if I had a dollar for every time I was asked - 'what should we do about XYZ' - there would be no financial problems to deal with!" My friend described feeling "you are the doctor - what do you think we should do?"

My friend was encountering a common medical ethics dilemma. We physicians are taught to provide "patient-centered" care, to "respect patient and family autonomy" and to avoid "paternalism." But as Dr. Ingelfinger described so poignantly, in the context of serious illness, patients and families also need support and guidance. Physicians need to develop communication skills that allow us to thread between respecting autonomy and providing structure and guidance.

There's no single right answer as to how to do this. I often found it helpful to (a) elicit the patient's goals and values, (b) give my view of what course of action these goals and values called for, but then (c) check on whether, from the patient's perspective, I'd gotten it right.

Over the years with medical students and residents I've often quoted Muhammad Ali's philosophy of boxing: "float like a butterfly/sting like a bee." Ali's eight-word formula conveys the need to embrace and integrate ostensibly incompatible components. Doing this takes experience. It also takes time.

I don't know if my friend's physicians felt rushed. My brilliant colleague Dr. Amy Ship recently wrote about how limited time constrains us in our efforts to be the best we can with patients and families. But whether or not time was a factor for my friend's physicians, Dr. Ingelfinger's guidance from his own experience as a patient holds true forty-one years after his lecture.

(Dr. Ingelfinger's lecture, published in 1980 after his death, is available here. "Physicians as counsellors," a previous post on a related topic, is here. )

Monday, July 23, 2018

Forest Bathing

For years I've enjoyed taking long walks in the woods. But it's only from reading a recent New York Times article that I learned I've been following the Japanese practice of shinrin yoku - "forest bathing."

There's nothing new about walking in the woods. Our ancestors spent their lives in forests. I assume many forest-dwelling genes are buried in our DNA. But as our species has become progressively more urbanized we spend most of our time indoors. A 2001 EPA survey reported that we Americans spend 87% of our waking time indoors, and another 6% in an enclosed vehicle!

In 1982 the Japanese Ministry of Agriculture, Forestry and Fisheries coined the term translated as "forest bathing" to describe the effort to imbibe what it saw as the healing power of nature by going into green areas with a mindful attitude. Since then, in the U.S., an "Association of Nature Forest Therapy" has trained and certified multiple cohorts of forest guides. A Google search shows that forest bathing is catching on as a commercial "back to nature" trend.

As an adolescent, Walden and Henry Beston's The Outermost House were among my favorite books. It seemed obvious that there was something very "natural" about being in "nature."

Three days ago the Journal of the American Medical Association published an important study demonstrating that creating green spaces of grass and trees on what had been garbage-strewn abandoned lots has a positive mental health effect on the neighborhood. This was a methodologically rigorous, randomized study that is likely to convince skeptics that there's more than sentimental anecdote behind the endorsement of time in the woods as a promoter of health and well-being.

In an aggressively capitalist society, it only takes a few nanoseconds for good ideas to become "monetized" and the focus for snake oil style hype. On the web I found vendors hinting that walking in the forest will combat cancer. But despite the hype surrounding the forest bathing concept, if I were still in clinical practice I would add spending time in "nature" as a recommendation to many of my patients.

Saturday, July 21, 2018

Medications and Religious Rituals

This morning as I put the pills I take into the pill container I fill each week, I thought about religious ritual.

On average, Americans over 65 take between 4-5 different medications each day. (See here and here for more information on pill-taking.) I noticed my feeling of pleasure as I put each of the 4 pills I take into the slots of the days of the week. I was carrying out an instrumental task, but the emotion I felt came from an entirely different realm.

I understood the rationale for each of the medications and found myself thinking of them as friendly presences, whose aim was to minister to my well-being. These thoughts led me to recall all the families I'd visited at home in my years of practice who showed me the Saints (Catholic) or Gods (Hindu) they prayed to and who they saw as crucial contributors to their health.

Although in theological terms I define myself as a "secular humanist," I respond to the pill-container filling with the same underlying emotions that my religiously observant patients felt about their Saints and Gods. It's important that I understand the medical rationale for the medications and their potential side effects, but I'm sure that a component of their efficacy comes from my attributing to them a benevolent intention to heal.

In the early 1970s I chose to work on the Jewish High Holidays, based on my lack of theological acceptance of the dogmas the holidays were based on. On Rosh Hashanah I was making a home visit to a Catholic family whose treatment I was involved with. They proudly showed me the little alter they used for prayer. It occurred to me that they might not have any more theological conviction about the Saints they prayed to than I did for Jewish theology. But unlike me, they were respecting the traditions and values they'd been brought up with.

From that day on, whether or not I was attending religious services, I didn't work on the High Holidays. I'm grateful to the family that taught me to distinguish between ritual, symbolic action, and literal theological beliefs.

In similar fashion, I'm grateful for the caretaking attitudes I associate with the medications I put into the pill container this morning.

(For a previous post on why religious language can be so valuable in clinical practice, see here, and for a discussion of physicians as "Counsellors," see here.)

Thursday, July 12, 2018

Ethics education and democratic values in high school and middle school

Every summer since 2012 I've taught at least one workshop on "making ethics part of high school and middle school English class" at the Bread Loaf School of English, a Middlebury College program in which the students, mostly teachers, can get a Masters degree in English in the course of 4-5 summers. I've written a series of posts on what I've learned in the workshops (see here, here, here, here and here if you're interested.)

I build the workshops around the issues the teacher-students bring to it. This year several teachers brought up the question of how best to deal with students who assert views the teachers regard as morally repugnant. They don't want to let the repugnant views go unchallenged but at the same time they don't want to put down the student. To squelch the student goes against the goal of fostering a classroom atmosphere of respectful deliberation, but to let the repugnant view stand can be seen as enabling.

The National Conference of Teachers of English (NCTE) statement on Academic Freedom urges teachers to cultivate democratic values in the classroom as a central objective:
NCTE maintains that students have the right to materials and educational experiences that promote open inquiry, critical thinking, diversity in thought and expression, and respect for others.
At the same time, the NCTE directs teachers not to proselytize or preach to their students:   

Educators and educational institutions must not require or coerce students to modify their beliefs or values. Efforts to convince students to modify their beliefs or values must be academically justifiable.
The teachers are in a difficult bind. They want to encourage  "diversity of thought," but human nature (and adolescence) being what it is, diversity can include prejudice, bias, and hate - the opposite of the "respect for others" NCTE calls for!

The teachers asked each other - "how can we best deal with this dilemma?" Three examples illustrate the kinds of strategies they suggested:
  •  After a hurricane, a  student said "why should we spend money helping people from XYZ?" This touched a very personal nerve - XYZ was where the teacher came from. The teacher kept anger in check and asked the class "does anyone have ideas about why we might want to spend money helping XYZ?" The question led to a thoughtful discussion. 
  • A student called a classmate "you bitch." The teacher used a jiu jitsu-like approach: "thank you for bringing that up - it lets us discuss the implications of the language we use..."
  • Another teacher described how she used "kindness" in dealing with cruel comments: "that might be hurtful...let's put it aside."
In medical practice and medical education we pay tremendous attention to the doctor/patient relationship. For teachers, "classroom management" has the same prominence. But the challenges I've faced over the years in relating to patients strike me as much easier than the challenges the teachers I've come to know at Bread Loaf have to deal with. 

As physicians, we're largely in 1:1 interactions, except for pediatricians, who deal with parents as well as the child, and geriatricians, who often deal with their patient's caretakers as well as the patient. Our field of action is less complex than a classroom that could have as many as 30 youngsters. And teachers typically must consider the expectations of principals and other administrators, parents and the school board in addition to dealing with a classroom full of bumptious students.

At the end of the workshop, I asked if the participants could help me pull together the wide-ranging discussion. The final comment, coming from an ex-teacher, was especially useful. He pointed out how much students learn from the way we comport ourselves and relate to them. Whatever the problematic situation we're dealing with, fairness, thoughtfulness and compassion will always convey "good lessons."

Recalling his comments put me in mind of Francis Peabody's 1927 address to Harvard Medical Students on "The Care of the Patient" that was given to us in a thin red booklet on our first day of medical school in 1960. Peabody's unforgettable final line rings true 91 years later. I expect the same will be said in 2118 and 2218: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Tuesday, July 3, 2018

Transmission of Values within a Profession

Last night I had the pleasure and privilege of having an extended conversation about medical ethics with Laurie Patton, president of Middlebury College. I was surprised when Laurie expressed great interest in my experience teaching medical ethics. Was she just being polite? It turned out to be much more than that.

Laurie explained that two months ago she’d invoked the Hippocratic oath and the influence of her surgeon father in an essay titled “Our Moral Directive,” in which she argued that “a Middlebury education should be accessible to all, regardless of financial means.” Here’s the opening paragraph:

My father is a retired cardiovascular thoracic surgeon. My childhood memories are punctuated with instances of him being called away from home for emergency surgeries. On those days, and many others over his long career, he never questioned whether the patients whose lives he was trying to save were able to pay for his services. He had taken the [Hippocratic] oath to heal to the best of his ability all those who presented themselves—and he spent his career doing so…In higher education, we don’t—yet—have our own official version of the Hippocratic oath. But at Middlebury, we do have a mission that serves as our moral directive… 

Our conversation and her essay conveyed a crucial insight into what it means to be part of a profession. As professionals we profess values imbibed from our teachers. Laurie invokes two - her father and Hippocrates. She treasures stories her father told about nurses in the operating room who saved him from making mistakes. From those stories she took lessons about respect for competent women, humility about one’s own expertise, and teamwork to serve patients.

Out of curiosity I Googled “Dr Patton cardiovascular surgeon.” What I found reinforced the lesson about transmission of values within a profession. In college Dr. Patton broke his collar bone playing hockey. Two of his moral influences were the surgeons who took care of him – their empathy, competence, positive attitude and the pleasure they took in their work. And in an essay of his own, Dr. Patton tells the story of Dr. Daniel Fiske Jones, a noted surgeon who graduated from Harvard Medical School 62 years before Dr. Patton did. The subtext of the story is that Dr. Patton is guided by the same values that guided Dr. Jones.

In my first year of medical school I experienced the process of value transmission directly. I was in a tutorial group that met with Dr. William Castle, a distinguished hematologist. Dr. Castle, who was 63 at the time, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:
Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel?
Dr. Castle: I would feel terrible!
Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)

Dr. Castle was a gentle, compassionate man who I admired. Over the years his story has led me to reflect on the challenge of how to be close enough to our patients to feel love for them, and at the same time to have enough internal "insulation" to maintain our own stability when our patients do not do well.

Laurie Patton is applying the values professed by her surgeon father. I reflect with my own students about the values Dr. Castle's teachers tried to pass on to him almost 100 years ago. 

That's a large element of what professions are all about!