“A disease and its
treatment can be a series of humiliations, a chisel for humility”
Laurel
Lee
“Fullness of knowledge
always means some understanding of the depths of our ignorance, and that is always
conducive to humility and reverence.” Robert Millikan
“Humility is nothing
less but a right judgment of ourselves.”
William
Law
“Early in life I had to
choose between honest arrogance and hypocritical humility. I chose the former and have seen no
reason to change.” Frank
Lloyd Wright
“Humility is the
foundation of all the other virtues hence, in the soul in which this virtue
does not exist there cannot be any other virtue except in mere appearance. Saint Augustine
Three physicians got me
thinking about humility.
At the health care
innovations summit in Washington, DC earlier this year, I heard Atul Gawande,
MD call for medical schools to do a better job at training physicians in
humility, discipline, and teamwork (http://careandcost.com/2012/02/03/notes-on-the-care-innovation-summit/).
In a 2010 Stanford School of Medicine Commencement speech, Dr. Gawande
stated:
“And
when you are a doctor or a medical scientist this is the work you want to do.
It is work with a different set of values from the ones that medicine
traditionally has had: values of
teamwork instead of individual autonomy, ambition for the right process rather
than the right technology, and perhaps above all, humility – for we need
humility to recognize that, under conditions of complexity, no technology will
be infallible. No individual will
be, either.”
Eric Van De Graaff, MD
wrote a blog titled “Why Are So Many Doctors Complete Jerks?” Dr. Van De Graaff
was chagrined when his own mother was disappointed when he became a physician;
she “had a deep-seated disdain for doctors.” Dr. Van De Graaff answered his own question with two
theories. His first theory was that some physicians “let the glory of their
careers go to their heads and begin to treat patients and underlings like
chewing gum on a movie theater floor.”
His second theory was that physicians act like jerks when emergencies
occur and they feel overwhelmed and frightened.
Dr. Van De Graaff offers
two simple rules, which he admits he sometimes does not follow:
“Rule
#1: It is simply not allowable to
be impolite, mean, nasty, or snippy with staff or patients even when you are in
a stressful situation.
Rule
#2: Whatever is stressing you is
probably stressing those around you as much or more. Under those circumstances
you have to go out of your way to be kinder and more understanding. As a doctor, you control the mood in
the clinic and operating room even if you can’t control the situation.” (http://www.kevinmd.com/blog/2012/08/doctors-complete-jerks.html)
A physician left the
following comment on the above Van De Graaff blog post:
“Frustrations
and stress mount, yes. I think in medicine we should be aware that continuing
bad behavior is partially the responsibility of us all. We have social
standards and maybe should ask ourselves how much have we allowed these actions
to continue? None of us function in a vacuum. We all have the ability to affect change and reward positive
communication.”
How do we as a community
of physicians respond to these three physicians who are clearly calling for
physicians to exhibit more humility in our practice of medicine? Do we know how to affect this change in
behavior in our colleagues and ourselves? T. S. Eliot once wrote, “Humility is the most difficult of
all virtues; nothing dies harder than the desire to think well of oneself.” (Shakespeare and the Stoicism of
Seneca. An address read before the
Shakespeare Association 18th March, 1927)
The English words
humility and humble are derived from the Latin noun humilitas and the adjective
humilis which can be defined as grounded, from the earth, respectful,
unassuming, modest, and low.
Humility is often contrasted with the terms pride, haughtiness, and
arrogance (See the Frank Lloyd Wright quotation at the beginning of this post). Humility has been held up as a virtue in
both religious and ethical writings.
Pride and arrogance are
commonplace among physicians and provide the punch line for the famous New
Yorker cartoon where a physician goes to the front of the line in heaven
“because he thinks he is God.” In the Christian tradition, part of humility is self-knowledge
about the limits of one’s own skills, knowledge, and authority. (http://www.wikihow.com/Be-Humble)
When a professional like a physician or a teacher does have superior
content knowledge when compared to the patient or the student, arrogance is an
all too common attitude. Bertrand
Russell was talking about teaching, but his lesson applies to physicians as
well:
“In
the presence of a child [the teacher] feels an unaccountable humility – a
humility not easily defensible on any rational ground, and yet somehow nearer
to wisdom than the easy self-confidence of many parents and teachers.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)
The Harvard psychiatrist
Robert Coles thought the greatest achievement of his mentor physician/poet
William Carlos Williams “was to teach doctors honest self-scrutiny, to show how
‘we become full of ourselves, self-preoccupied, so caught up in either our
importance or our own affairs that we can’t listen and pay attention to other
people, even our patients at times.’”
(Carlin Romano. America the Philosophical, New York: Knopf, 2012).
Honest self-scrutiny of
physician limitations is particularly relevant now that medical group
practices, hospitals, and integrated delivery systems are undergoing process
work redesign in order to respond to federal health care and payment reform. Socrates criticized craftsmen and poets
for assuming that the knowledge and expertise they acquired in one area meant
that they were experts in any area under discussion. (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf) Having sat in on many lean workgroups, there is a tendency
for physicians to pontificate on subjects about which they know little.
Another component of
humility in Christian teachings is the recognition of the contributions and
skills of others (http://www.wikihow.com/Be-Humble). Dr. Gawande has spoken eloquently about how
traditionally medicine has emphasized independence and autonomy (acting like cowboys) and
how the complexity and need to decrease per-capita costs now require physicians
to work effectively in interdisciplinary teams, even when they are not the
designated leaders (acting like pit crews) (http://page2anesthesiology.org/2011/teamwork-humility-and-generosity-opening-session-with-atul-gawande-m-d/) In my experience consulting with physician
groups, I have noticed that doctors are much more willing to listen to another
physician, rather than a non-physician advisor who may have more content
expertise relevant to the problem under discussion. Developing more skill in this component of humility would
help develop effective and efficient teams.
If the physician does
not maintain the correct balance between authority and humility, difficulties
can arise in taking the patient’ s story and wishes seriously or in not
critically assessing the patient’s wishes that may be unknowingly harmful to
his health. Dennis Gunning
discusses this ideal balance in teaching history:
“It
is hard for a teacher not to feel uneasy when faced with a fourteen-year-old
giving an unorthodox interpretation of a piece of source material. We really have to school ourselves not
to ‘put him right’, not to sweep his interpretation aside (or, equally bad,
apparently accept it, but in such a way that everybody knows that we are just
humouring the student.)” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf)
One does not have to
recall that the first definition of doctor in the Oxford English Dictionary is
“teacher, instructor; one who gives instruction in some branch of knowledge” to
see how Gunning’s advice might apply to the physician/patient
relationship.
How difficult and
important this balancing act can be for physicians is highlighted by our need
to continuously improve the care we give our patients. Henry Sidgwick in 1874 commented on how
strange it is for those who are experts to embrace a humility that requires a
low opinion of one’s self. Would it make more sense to try for an accurate
appraisal of one’s abilities? “Sidgwick suggested that the value of humility
lay in its ability to temper the emotion of self-admiration, and to prevent
appropriate self-esteem…from turning into self complacency.” (http://www.williamhare.org/assets/hare_humilityasvirtue.pdf) Sidgwick believes that those who lack humility
will exhibit self-satisfaction and complacency that will prevent the
recognition of the need for continuous improvement.
When organizations need to
change behavior, they rarely consult philosophers and theologians about
humility; they usually look to rules with some sort of policing mechanism and
incentives. And we now have
hospitals and payers instituting rules governing physician conduct, pay for
performance incentives, and patient satisfaction surveys to encourage us to
improve. I have described
elsewhere why physician report cards are fraught with difficulties (http://thehealthcareblog.com/blog/2010/08/21/trust-me-im-a-doctor-vs-physician-quality-report-cards/ and http://kentbottles.blogspot.com/2010/08/physician-quality-report-cards-part-ii.html) and why pay for performance programs often fail
(http://www.kentbottles.com/pdfs/Pay-for-Performance-Why-It-Will-Not-Work.pdf).
Barry Schwartz and
Kenneth Sharpe in Practical Wisdom: The Right
Way to Do the Right Thing (New York:
Riverhead Books, 2010) make a convincing argument that hospitals and
medical groups should add training in practical wisdom in addition to their
rules and incentives. Drawing upon
Aristotle’s Nicomachean Ethics, they think physicians need to be able, with
humility, to choose between “right things that clash, or between better and best,
or sometimes between bad and worse.”
“Rules
can’t tell experienced practitioners how to do the constant interpretation and
balancing that is part of their everyday work. Consider the doctor who has been
well educated in the rules of how to practice medicine, but is constantly
called on to make more complicated decisions. How should such a doctor balance respect for the autonomy of
her patients when it comes to making decisions with the knowledge that
sometimes the patient is not the best judge of what is needed? How should the
doctor balance empathetic involvement with each patient with the detachment
needed to make sound judgments?... How should the doctor balance the desire to
tell patients the truth, no matter how difficult, with the desire to be kind?”
Schwartz and Sharpe
teach us that practical wisdom “depended on our ability to perceive the
situation, to have the appropriate feelings or desires about it, to deliberate
about what was appropriate in these circumstances, and to act.”
My favorite example of
practical wisdom is their discussion of a hospital janitor who cleans the room
of a comatose young man and then later is confronted by the patient’s father
who claims the room has not been cleaned.
The janitor exhibits practical wisdom by remembering that his goal is to
care and comfort patients and their families, and so he cleans the room again
so the father can see him do it.
“And
when the angry father confronted him, Luke also had to sort out conflicting
aims. There were other legitimate
things he might have chosen to do.
Be honest: tell the father
he had cleaned the room already.
Be courageous: stand up to
the father’s anger and refuse the unfair demand to clean the room again. But Luke had to determine how to
balance these competing aims in this circumstance.”
It seems to me that a
better and deeper understanding of humility by the physician community of the
United States would serve all of us well in this time of rapid change and
health care reform.
