Winter 01/02

To Keep It, Give It Away

The most important thing for physicians is not what they take away from their profession but what they bring to it.

Let me tell you a story. Because this story has to do with alcoholism and addiction, it may strike you as gloomy. The very word alcoholism conjures up impressions of sadness and suffering. Yet it is frequently in sadness that we discover what is most worth caring about, and through suffering that wisdom is born. In fact, this story embodies one of the most important truths I have learned in medicine.

Among the bad habits in which we Americans indulge, alcoholism ranks second behind cigarette smoking in the number of deaths it causes each year. Many alcoholics find it impossible to give up drinking and, as a result, end up destroying lives: their own, their families', their friends' and those of strangers who they kill through drunk driving.
Over the years, medicine has made many attempts to cure alcoholism but, despite recent advances in molecular biology and pharmacology, the most effective treatment remains one originally developed in 1935: Alcoholics Anonymous. Let me tell you a story about A.A.

Bill W., one of the two founders of A.A., had tried repeatedly to stop drinking, but could never abstain for more than a week or two. Desperate to achieve some success, Bill decided that he would stop trying to quit himself, and instead focus all of his energies on his friends. If he couldn't achieve sobriety, at least he could help his friends abstain from drinking. After six months of intense effort, he was in despair. He told his wife, "I tried everything I could think of, and still not a single one of my friends has managed to stay sober. I have failed." His wife had a simple yet sage response. "No, you haven't failed," she told him. "True, none of your friends has managed to quit drinking. But Bill, you haven't taken a drink in six months."

Through this experience, Bill identified one of the fundamental principles of A.A.: "In order to keep it, you have to give it away." One of the greatest problems confronting alcoholics is overwhelming self-absorption.
As people descend into alcoholism, their lives revolve increasingly around drinking, especially when and where they are going to get their next drink. A.A.'s twelve-step program works by helping alcoholics find new meaning in life, a meaning that transcends their own needs.

Through A.A. meetings, alcoholics get a chance to live for something larger than number one, by committing themselves to the sobriety of others. Only by investing ourselves in larger purposes can we find the means truly to flourish as people.

Many forces in our culture tend to foster a pernicious form of self-absorption. Happiness, we are told, lies in consumption, and the key to success in life lies in being able to afford to buy the things you need to make you happy. As money becomes the driving motivation of a career, people soon devote their time and energy to two things: spending what they have and making more money. Ironically, the overwhelming self-absorption that characterizes both addiction and avarice leads to the destruction of the self. The same thing can happen in internship and residency, where unrelenting demands on your time and energy can leave you thinking only of yourself.

So long as money is our model for what's worth keeping, sharing seems absurd. In giving money to others, we necessarily diminish ourselves; if you give me five dollars, then you are five dollars poorer. Where money is concerned, giving it away implies a failure to keep it. Yet money is not the only thing we have to share. In fact, there are some goods that we can only keep ahold of by giving to others. Far from diminishing, such goods actually grow in the sharing. This riddle underlies the wonder of the loaves and fishes in the Gospel of John, where but five loaves of bread and two fishes prove enough to feed five thousand, and afterwards, twelve whole baskets are left over.

Before proposing a solution to this riddle, let me point out some ancillary benefits of sharing. First, people with whom we share are more likely to share with us. If you never open yourself up to the people you work with, you will never get to know them very well, and your relationships will remain superficial.

Second, giving helps us to better appreciate what we really have, and to discern what is most important. People who can't contemplate giving away their money betray a failure to understand its true value. The ability to give liberally implies liberation, freedom from enslavement, a capacity to live without hoarding what you have.

Finally, sharing helps us to distinguish between what is worth having because it is a means to something else, and what is worth having in itself. Money is valuable only as a means to other things, but certain other things - which, incidentally, can't be purchased - are valuable even though they can't be exchanged for anything else.

So, what is the solution to the riddle? What isn't diminished, and in fact grows, through the sharing? One such good, to which physicians are invited to devote their lives, is knowledge. The word "doctor" comes from a Latin root meaning to teach, and to be a doctor is to be a teacher. What does a teacher share? Knowledge. One cannot understand a patient's history, perform a physical exam, order diagnostic tests, prescribe therapy, or care for patients in any meaningful way without knowledge. In fact, caring for the patient means sharing knowledge, not only using what the patient gives you to arrive at a diagnosis and treatment plan, but educating the patient at every step of the way.

In teaching others, we do not lose knowledge. In the first place, when we share what we know with others, we are not engaged in a zero-sum game. When what one person once knew becomes known by two, the total amount of understanding in the world is increased. Furthermore, he who teaches learns twice; that is, we come to understand our subject better through the teaching of it. If there is something in life that we really wish to understand better, we can set about teaching it. Finally, sharing knowledge means not only downloading information but inspiring the yearning for understanding in others. Human knowledge is not fixed, and in fact we are learning more and more all the time. If we are to be good physicians in the years and decades to come, we must fan the flames of our own passion to know. The moment we cease learning is the moment we begin to become obsolete.

We need curiosity every bit as much as we need information. If medicine is to advance, we need physicians who think of themselves not as "know-it-alls," but as seekers, people who fervently wish to know more. We need physicians who seek out what we don't know, who prize questions above answers, and who have the resourcefulness and curiosity to undertake the quest of discovery.

Knowledge is important to us not only because it constitutes the foundation of our professional work, but because none of us can lead full and rich lives unless we understand what we are. Medicine affords us myriad opportunities to grasp what it means to be human. In birth and death, reproduction and decay, human redemption and tragedy, physicians come face-to-face with poignant situations where the real meaning of human life is brought into sharpest focus. Many factors in our professional lives conspire to blind us to these insights, but if we remain vigilant, we may see that shining truths are all around us if only we can perceive them. In sharing that knowledge with our patients, our colleagues, and our families, we enjoy the opportunity to illuminate their lives as well.

In sharing lies the key to unlocking greater significance in our own lives. It is an extraordinary privilege to devote our lives to a calling in which people regularly share with us their stories, their life's work, their deepest hopes and fears - essentially, who and what they are. Some aspects of a medical career threaten to make us one-dimensional; locked in routines we proceed through life with blinders on, attending only to what laboratory tests, clinic schedules, and balance sheets reveal.

To paraphrase José Ortega y Gassett, in order to be a physician, it is not enough to be a physician. To excel in medicine, we must attend to additional dimensions of our patients' lives - not just their physical exam findings and radiological reports, but what their illnesses mean to them in the context of their distinctive biographies. In order to fully care for our patients, we must know them as human beings.

Time constraints, financial pressures, and overwork may conspire to separate us from our patients. Soon we suppose that we simply can't afford to care. By holding back from self-investment, however, we end up devaluing medicine. You cannot really skate so long as you cling to the side rail, and you cannot really swim while clutching the side of the pool. There is risk in investing ourselves in medicine, giving our best to our patients. Often it is both safer and easier to hold back. Yet in holding back, playing it safe, we lose more than we gain.

In medicine, happily, meaningfulness lies all around us, if we can but open our eyes and see it. Our excellence as physicians is revealed not by our investment in the stock market, but by our investment in the lives of others, our capacity to understand their situations, and to sustain and enrich their lives. The most important thing we have to invest is not what we take away from medicine, but what we bring to medicine. The most important thing we have to invest is not our money, but ourselves.

It is through sharing, by investing the very best we have to offer, that we find what is most precious in medicine, what I have learned: In order to keep it, we have to give it away.

(Richard B. Gunderman, MD, PhD, is vice chairman of the Department of Radiology, director of pediatric radiology and an assistant professor at IUSM)