My compass

As a physician for 35 years, I have strived to live up to a quote I first heard from my father: the goal in medicine is to cure sometimes, to relieve often, and to comfort always. During my more than three decades of practice, I have learned that one must combine a willingness to care and ability to hear with an offer to help in order to comfort – let alone occasionally heal. It has been - and continues to be - a glorious and fulfilling career. But it has not been easy or without pain, confusion, fear, or despair. I get asked by younger clinicians how I have survived with my love for medicine intact. The simple answer is that I love my patients and that the regular contact and sharing involved in our long-term relationships is a magic elixir with the power to restore and rejuvenate.

But that is not the whole of it.

There is also what Donald Berwick so eloquently calls the compass which always points to true north. (His Harvard Medical School address from 2012 can be seen here and thetranscript is here .)

True North is the patient. Medicine is a field littered with bewildering and often incompatible rules, standards, targets, goals, and algorithms. Ultimately, though, there is only one metric that matters: How will this help the patient? That is the question I ask myself to stay on course in the midst of the high-paced chaos we call medical practice. It is the question I use to prevent distractions like productivity, revenue targets, or meaningful use from distorting my care and harming my patient. It is the the antidote that prevents pragmatics from poisoning purpose. It is the only question whose answer is always a valid reason for the recommendations I make in the exam room. Yes, there are other important questions; but this one should - must - trump them all.

Like Dr. Berwick, I deeply believe that I am morally obligated to focus on True North; that is, to practice medicine based on what is good for my patient. This is not some kind of didactic knowledge to be acquired in school or from books. It is a deeply personal tacit or experiential knowledge, and is grounded in how I feel when I focus on the patient, and how I feel when I do not. I could not have practiced medicine for three and a half decades without it. It has often made my life harder, of course, but I would not want to lose it.

My compass is necessary but it is not sufficient. Knowing which path to take does not get me to my destination. There are three other pieces: my job, my person, and my calling. 

  • My job is to bring all the science, evidence, technology and skill I can muster to bear on the patient’s health needs. This is hard work, but it is by far the easiest of my tasks to understand and accomplish. It requires only time and energy. It requires LOTS of time and energy, and it can be discouraging to know that the job can never be completely or perfectly accomplished, but it is not frightening or overwhelming in the way the other two pieces are. The clinician who masters this task but no others will be a skilled and knowledgeable technician, but not a healer. 
  • My presence is necessary. I don’t mean my physical presence but my spiritual presence. My patient must feel and believe that I am there, that I care, and that this drives me to try to understand and help, without judging. I have never been sure to what degree this is something the best clinicians are born with, and to what degree it can be learned or taught. 
  • My calling is to help the patient, a task that is only partly accomplished by being present and doing my job. Just as I cannot help the patient if I think of them as a pneumonia or elevated blood sugar, I cannot truly advocate for my patients if I do not understand that they live and struggle in a social context. My patient is not simply a covered life that spends 20 minutes in my exam room four times a year. My responsibility goes beyond making those 80 minutes as useful as possible. My patient is part of a family, a community and a society. She has strengths and weaknesses she did not ask for and may not understand or be able to use. Her capacity to heal and grow have been enhanced or curtailed by what has happened before and by what her culture and society provide. All of this is part of the patient I am trying to help.  It may be true that what happens in Vegas stays in Vegas, but it must never be true that what happens to my patient outside my office stays outside my office. Limiting my awareness and professional efforts to what happens in the exam room is, in my opinion, profoundly immoral. The same applies to the impact my practice and my hospital have on my patient. It is not enough for me to expertly and compassionately do my part for the 80 minutes I sit with the patient. I must also do everything in my power to understand the systems I am part of and take action to make them serve my patient rather than expect my patient to adapt to my office, medical group, or my hospital

Dr. Berwick most often talks about this moral calling in terms of national policy and society, but it is fractal. It applies at every scale. All politics are local. My ability to change national health care or economic policy to make them better for my patients is so small as to be delusional, though this is not an excuse not to try. It just means that voting, an obligation of citizenship, is not enough. I am also morally obligated to speak out when I see something wrong. Saint Exupery said that being a responsible citizen means being ashamed of miseries we did not cause. Speaking out and pitching in are my professional responsibilities, just as keeping up with the medical literature is, just as prescribing the correct medication in the correct dose, or making the correct referral to the correct resource. I may not have the clout or profile to make an impact on national policy, but I live and work in a much smaller environment, where I frequently can make a difference and certainly must try. In my primary care practice, at my hospital, and in my local medical community it is essential that I be ashamed of miseries I did not cause and be willing to speak out and pitch in, to make people aware, and to contribute to solutions. The obligation to point out that the Emperor is wearing no clothes is part of my obligation to my patient. This is not a sure path to popularity and can result in labels like PITA (pain in the ass), troublemaker or disruptive physician. But true change always starts with behavior at the margins. I call this trickle-up citizenship. Systems analysis and management science have long recognized that most quality and safety failures are systemic rather than a result of individuals, and systemic problems require systemic solutions. Systemic solutions only become possible when individuals refuse to allow the system to dictate their behavior. 

In short, I work for my patient because I care for my patient. My role includes a technical component, a personal component, and a moral component, all three of which are only valuable to the extent that they benefit my patient. And I wouldn’t have it any other way.


 

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