Winter 04

Passion for the Profession

The study and practice of medicine is an extraordinary blessing, a lifelong learning process and a challenge for those who pursue it, notes Thomas S. Inui, ScM, MD, associate dean for health care research, in this thought-provoking essay.

There has been a remarkable flurry of interest in professionalism in medicine the last decade. By any indicator one might choose – the appearance of new essays, research, curricula, development of measures for feedback, and innovation in certification and continued learning – physicians have been in very active discussion about what it means to be a professional. We can all speculate about why this is happening. I personally believe that it emerges from our profession’s search for meaning and clarified values in distressing times.

The professional discourse in this same decade has also been remarkable for the appearance of a number of statements on the values and virtues of the good physician. One statement that comes readily to mind is from the Association of American Medical Colleges’ Medical School Objectives Project. This project was a serious effort by the national association of medical schools to specify what we aim to produce as the most important qualities of the future physicians we educate. At the close of these deliberations, it was concluded that schools should prepare future physicians to be knowledgeable, skillful, altruistic and dutiful.

In this and many other statements on professionalism from individual essayists and professional organizations, there has been a remarkable degree of congruence about what I consider to be the ideal attributes and behaviors of a virtuous person in medicine, attributes that reflect the foundational values of the profession. I describe these values as …

• Seeking truth, using science as the best approach to truth, practicing evidence-based medicine
• Establishing therapeutic alliances with patients and families
• Curing and healing when possible, caring and comforting always
• Being accepting, empathic, open-minded and open-hearted
• Pursuing right action, avoiding error
• Being reflective, mindful and analytic
• Being altruistic, putting the patient’s interests first

When advocating these values and ideals, as we undoubtedly will in lectures that lie in your future, we are explicit. In the real world of our lived experience, however, pursuit of these ideals is fraught with ambiguity and difficulty.

Even with top-quality evidence from randomized trials in hand, it is not clear what to do with the individual patient. In the pursuit of evidence-based medicine, for example, if ninety percent of patients have been shown to benefit from treatment A versus sixty percent from treatment B, we conclude that we should, in general, recommend treatment A. However, when a particular patient sitting in front of us asks, “Doc, is this treatment really going to work for me?,” we actually have no way of knowing whether she is in the ninety percent or the ten percent of responders to treatment A.

Conflict and Values

The difficulties continue. Conflicts of interest are common in medicine. Every potentially effective therapy also risks harm. Some situations in practice clearly seem to demand the medical arrogance of an often wrong, but never uncertain doctor. While we seek to be error free, we know that we’re mistake prone. Knee-jerk reasoning is a way of life in some domains of medicine, and health economists remind us that homo economicus is a fair caricature of the physician. None of these situations is wholly avoidable, but in our usual talk with one another we are silent about these compromises struck with daily circumstance. The silence is regrettable, especially in our role as educators, because you might conclude that we are either unaware of the compromise, numb or malicious.

I’m telling you this not to distress you, but to make explicit what some of the challenges are that we face every day as members of the IU School of Medicine community and as your teachers. I’m also positing this perspective because I know how you learn. I know that you will learn most powerfully about the profession you have joined not from lectures, but from your own experience among us, as participants in the life of the community you have joined. The compromises with circumstance, the ambiguities, and the uncertainties we feel and embody will be visible, but may not be openly discussed.

In this situation, I fear that you may conclude (having heard about our values and seeing us do some things apparently in conflict with our values) that medicine is a field in which we say one thing and do another. I fear that you may conclude that we are cynical and that you must be cynics too. But we are not cynical.

Discovery and Wonderment

We may be inarticulate and given to silence in our most trying moments, but we are truly trying in every moment, doing our best to embody our ideals. As evidence to this effect, I thought you would be interested to hear a summary of recent in-depth interviews a team of interviewers has been carrying out at the IU School of Medicine during the past six months for a special project on education. The members of the team – volunteers from among the faculty, residents and students – have been talking with their peers and gathering their responses to several questions.

I wish I could recount many of the stories that have emerged from the first eighty interviews. They are all remarkable in one way or another – moving, inspiring, evocative of events in my own life, reminders of why I got into medicine in the first place and, taken together, a rich portrait of community life in the IU School of Medicine. The team has found four major themes in these stories. I present them here as summary statements about what we in the IU School of Medicine community believe – in other words, our credo.

We believe in the wonderment of medicine, the profound nature of our work, and the deep meanings expressed by what we do with our patients, one another and our community.

We believe in everyone’s capacity to learn and grow. Given freedom and support, we all (students, faculty, residents, patients and their families) seek to learn, to grow as persons and to pursue these positive developments both for ourselves and for one another.

We believe in the importance of connectedness. Students and teachers, clinicians and patients, and interdisciplinary teams working together are all aware of their interconnectedness and greater capacity together than as individuals.

We believe in the importance of passion – passion for learning, passion for teaching, passion for new knowledge and for innovation. Whatever your notions about academe may be, it is not sheer intellect that moves us from moment to moment, but the combination of heart and head, intellect and emotion. Passion energizes us in every activity.

I will end with a story from the discovery team interviews,
from a faculty member about a patient and a student. The faculty member said:

“While doing VA staffing, I had a patient who had cancer and eventually lost both kidneys, got on dialysis, and had a stroke. An Indiana farmer, he had been an extremely independent man who was now very dependent because he couldn’t speak his thoughts readily and he couldn’t drive a vehicle. He was miserable. Then he had a heart attack and was placed in the ICU. Once out, he said he never wanted to return to the ICU again and didn’t want any more therapy. I had a junior student, Chris, in his first rotation, who got very close to this patient.

“While I was out of town one weekend, the patient died. Chris took it hard. He had worked with the patient and his family, mainly his daughter, to help them understand their options, both medical and non-medical. When I came back I called the daughter, thinking she might be upset that I was out of town when her father died, but she was fine. A very religious woman, she told me that her family wondered a long time why God had allowed her dad to suffer so much and for so long, but now she knew why. She said her dad went through all that and died to make Chris a better doctor.”

So here is what I hope you understand: the life of the profession you have chosen is a miraculous life. It is both a blessing and an extraordinary challenge. You will emerge into this profession in the company of people you do not know today. We have been waiting for you. We are here because we love the wonderment of medicine, love teaching, love helping you emerge as full-fledged professionals. Your lives and ours will entwine.

We are not superhuman, not perfect and certainly not always articulate. We are a diverse community of faculty, resident trainees, fellow students, other health professionals and patients, all of whom will be part of your becoming the person you will be in the profession of medicine. Welcome to the community.

Editor’s Note This commentary was excerpted from remarks delivered last August at the White Coat Ceremony, welcoming new students to the IU School of Medicine. In addition to his research and faculty duties, Dr. Inui serves as president and CEO of the Regenstrief Institute Inc.

Discovery Team

For more than a half a year, Dr. Tom Inui has led a volunteer team of faculty, residents and students who are tasked with conducting interviews and collecting information how the IUSM community views professionalism in medicine.