Wednesday, June 24, 2009

The Ethical Culture of Medicine

I'm in the Green Mountains of Vermont now, where my wife teaches for 7 weeks at Middlebury College's Bread Loaf School of English. (The campus is at the foot of a mountain that looks like a loaf of bread - thus the weird name!) The opening ceremony last night got me thinking about the culture of medicine in the U.S.

The ceremony welcomed the 250 students - mostly high, middle and elementary school teachers themselves - who can get an M.A. in literature in the course of 4-5 summers. The faculty (from colleges & universities in the U.S. and U.K.) has lots of veterans who've taught here for 20 years or more. In the course of the ceremony 7 faculty plus the president of Middlebury College all spoke. Warmth and enthusiasm are expected in a welcome, but what stood out for me was the depth and consistency of the values that shaped each of the talks. They spoke lovingly of the students and the important work the students do. They spoke lovingly about the enterprise of teaching and learning. And the sense of camaraderie among faculty, students and staff was palpable.

For most physicians, nurses and other clinicians there are very few gatherings in which we explore and reaffirm the ideals of our profession. Our meetings focus on administrative problems. Grand rounds can be engaging, but passively listening to a lecture while a powerpoint flashes by doesn't often engage us with the wellsprings of our values.

One of the major delivery system changes being discussed in the reform dialogue is forming "accountable medical groups" - groups of physicians that can take responsibility for the quality and cost of care for a population. Atul Gawande's New Yorker article and a followup interview with Ezra Klein take the concept beyond administrative accountability. Our health care organizations need to reinvigorate the soul of the health professions.

Doctors cherish the deep satisfaction in helping a patient achieve greater health, and, when we can't do that, helping individuals and families make the most of the life they have. But too many doctors lack collegial settings in which they feel allied with others around their most important values. Except for the rare person who is 100% inner directed, the sense of mission and purpose degrade in the absence of group support.

I interrupted writing this post to play tennis with a friend who has taught here for 25 years. When I told him my reaction to the welcoming ceremony he said - "this institution commands my loyalty more than any other I've been part of." We clinicians need more of that experience in our professional lives!

(See this post about the Swami Vivekananda hospital in Saragur, India, for a discussion of how that institution supports its sense of calling.)


Charles said...

I couldn't agree more, being up here in the mountain with you, Jim!

Though in fairness to the medical profession (and in reflection of the comment about the loyalty that Bread Loaf commands), I think that BL is very much the exception as far as 'collegiality' goes. My university experience during the academic year couldn't be more distant.

I'd also be curious to hear how you think that this culture could be brought about for the medical profession. One thing, of course, on BL's side is that it is highly self-contained.

Jim Sabin said...

Hi Charles -

Thanks for your comments!

I agree that a program on a self-contained campus in the Green Mountains has some very special things going for it. But the key ingredients - public "profession" of values and collegial reinforcement of shared commitments can and should be fostered in other settings.

As an example of how this can be done without being on a magic mountain, I recently heard about how an orthopedic department has instituted a 5 minute "huddle" at the end of the work day. Surgeons, Physicians' Assistants, and support staff quickly review what went well and what needs to be fixed. That brief collegial exchange has improved the group's effectiveness and is heartening for the staff. Medicine, like teaching, can be a very isolated pursuit. Collegial cooperation diminishes the loneliness factor and helps to reinforce our sense of what our pursuit is all about!