Tuesday, May 29, 2007

How I changed, part 2: love and faith

Image: from Harvard Medical School's Countway library: a fifteenth century view of the Antichrist being born by C-section.

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More in how my view of the world has changed since I started medical school, now that I’m graduating:

Before medical school, I used to believe that people were inherently good and that their bad qualities were the product of bad events that happened later. Now I don’t believe that people are inherently anything. Now what I wonder about is whether it is still important to love them.

I understand now that the willingness to try to love everyone in some way is not based on some factual insight about character, but on a large and partly irrational secular leap of faith. For example, when I am feeling nervous about a public speech, one of the things I try in order to summon the best part of myself is to actively think about loving the members of the audience, each one of them. This allows me to try to be my most generous, my most honest, my most enthusiastic. They may not like what I say or how I say it, but if I am in this mood, at least I can be sure that I have given them the gifts I have to offer, as best I can. Loving them is not the same as thinking that they are inherently good (whatever good is), but maybe it involves some faith in their potential for goodness.

At least sometimes, this is how I think I want to be a doctor. And talking about this to Ms Hemodynamics, I said, “I think I need that faith to be a good primary care doctor.”

Ms. Hemodynamics disagrees with this idea. She says that being a good physician means meeting people where they are, whether they’re good or bad; whether they’re good or bad isn’t even part of the question. And she says that she believes that who ever you are, you don’t deserve to suffer, or to be afraid, and that a doctor should believe that; but that a doctor does not need to believe that people are good, and does not need to love them.

I know that she and I both reserve some of our most pointed skepticism about a set of doctors who would at first seem to have much in common with us in their politics and their relationship to the medical-industrial complex. These doctors claim to love people, but actually when you get to know them as clinicians or teachers, you realize that sometimes they love The People more than they love actual people. And one can’t help but think that some portion of them love the idea of being loved by The People more than the idea of actually loving them. The line between The People and actual people is a fine one, but I want to stay on the right side of it: I’m no Ché Guevara, and I’m in no way convinced that The People even exist.

So maybe her approach is the best one: don’t worry about who the people are, or who The People are, and don’t worry about loving them, and definitely don’t worry about being loved by them. Just meet them where they are; figure out what they need; help them get it. When I think about it, this is how I often operate in a day-to-day way.

And yet I think that when I do the best job it is at least sometimes because I have found some kind of love for my patients. This is not always with my most lovable patients. In fact, to persist in trying to do a good job for some of my least loveable patients, I sometimes need to remind myself to try to love them—and that when I do, I often do a better job. This is an active process of trying to summon up some version of Buddhist loving-kindness—again without believing in the larger Buddhist scheme of things. The challenge, I think now, is to love people without becoming attached to the outcome of that love—to not be too upset, for example, when you know a patient is saying one thing to you and actually doing the exact opposite.

“But I love you,” some internal voice of mine has said at a couple of times in medical school with patients I’ve hoped might behave differently, mostly without clear words but just the feeling: “Why are you lying to me and letting me down?”

Given the inevitability of the range of human behavior, including some not entirely palatable kinds of behavior, and the inevitability that some of that behavior will take place in a clinic or in a hospital, it may be too much to ask of myself to love my patients. Or it may not. I’m not sure.

What I think now that is different from before I started medical school is that I don't think that people are inherently good, or inherently anything; I've stopped expecting to be able to find that in everyone. To walk into the clinic expecting something from one’s patients is a sucker’s game, and a sure path to bitterness.

Is unconditional love for my patients the cure for the cynicism that comes from disappointed expectations? Or is it a risk factor for disappointment, and thus, cynicism?

Or, probably most likely, both?


Ms. Hemodynamics said...

How do we know that's the Antichrist? Everyone (except for the woman who needs to be sewn back together) seems pleased as punch!

Joe Wright said...

The Wikipedia entry on the Antichrist leads me to believe that it is pretty hard to know who is going to be the Antichrist.

Wikipedia Antichrist article

So, I can only go with what the Countway Library tells me:

De revelatione facta ab angelo Beato Methodio in carcere dete[n]to
(Basel: Michael Furter, [5] January 1498)

This book of prophecies attributed to the fourth-century martyr, Methodius, was probably composed by a fifteenth century monk, Wolfgang Aytinger, to arouse animosity between Christians and Muslims. Although not specifically medical, the De revelatione contains a number of unusual woodcuts, among them this image of the birth of the Antichrist—which is also one of the earliest printed depictions of a Caesarian section birth. There is a long iconographic tradition of linking the Antichrist with a Caesarian birth, hinting at the suspicion and distrust surrounding this "unnatural" procedure.

So apparently, the C-section is the clue that is supposed to tip off the viewer that this baby is going to be a tool of the Devil.

Nicole said...

I think that Ms. H has a good strategy because in the long run trying to keep that unconditional love alive is exhausting. I think one might do a better job if one doesn't try to love. Love is work. Not the work that you have necessarily signed up for, so now you have two jobs. Isn't there an inevitablity that one of those will give out at some point? That is not to say you should have a distance from your patients. Kindness and understanding are good, but they don't carry with them the commitment of love even temporary love.

Joe Wright said...

I think by "love" I probably mean something that might be at it roots basically Christian--but without the religious part.

I googled "love your patient" and immediately found a Google Books extract from a book written by a psychiatrist who was a preceptor of mine: Doing the right thing: an approach to moral issues in mental health treatment (by John Peteet, MD):

Does a resident presenting a case to her supervisor show evidence of compassion? Does she feel responsible to act on her concerns for the patient? Does she know how to meet the patient’s needs, or does she (for example) mistake comfort for nurture? Can she recognize and correct mistakes? Does she show a balance among these capacities—for example, between following Semrad’s injunction to “love your patient” and Bettleheim’s caution that “love is not enough”? Does she instead show signs of sentimental overinvolvement, moralism, or a preoccupation with technique or detail? Understanding the moral tasks involved provides a basis for addressing specifically such problems in caring.

Joe Wright said...

...and I'm not sure what this all leaves me with. Except that some connection to patients is important, and I'm not sure what to call it, or how to make it manifest.

Nicole said...

Maybe, in the Christian sense, but the Christian sense carries with it the a sense of . . . moral superiority or maybe even judgement. As in, I must love you because it is required by my character. It's all semantics. Compassion sounds condescending. But love sounds, well frankly, a little melodramatic. Connected, in tune--a little California.

Perhaps it is something that should just go without saying. Perhaps the baseline assumption is that you have to respect and value your patients otherwise you are not doing your job.