Pointing Towards Virtue

Image result for finger pointing at the moon koanThe 2017-18 year is underway, and this is usually the time for orientations, “boot camps”, links to useful resources, etc. I have some some of the last queued up for soon-to-follow posts, but first wanted to address a deeper matter.

A few weeks ago, I received a survey about character education in residency. It was comprised of questions like “Where in your residency program do trainees learn virtues such as honesty and integrity?” I found this line of questioning to be exasperating on a few counts. First, residents are adult learners—not schoolchildren. I presume that they will have developed their moral virtues well before entering residency training (at an average age of around 30). When and from whom do they learn moral virtue? Years prior, from their parents, school teachers, coaches, clergy, etc.

Moreover, to whatever extent people are lacking in certain virtues by the time they reach adulthood, they are not going to acquire them in a residency program—that ship has sailed, I thought.

Finally, I resented the implication that moral virtue could be codified as a set of behaviors or “competencies” to be checked off a list as part of yet another training milestone. If anything were to exemplify what I previously termed “competency theater“, this would serve splendidly.

And yet, as we roll into month #2 of this new year, I think that my initial reaction to this moral inquiry may have been too flippant. Consider that the Greek origin of  “character”, kharássō, means to scratch or engrave. It implies a process and not a fixed state—a process that, over time, imparts one with distinctive traits. Are residents not amenable to ongoing engraving of character? Aren’t we all?

Furthermore, it perhaps should not be taken for granted that virtues developed in the context of family life, grade school, etc., will always manifest in the context of residency training. This might be especially true when the virtue hasn’t really been tested before. Some young people might not yet have been in situations where they must choose whether or not to subordinate their own interests to those of another, or whether to be fully honest at the risk of great personal embarrassment or inconvenience. We all presumably learn about the moral virtues during our upbringing, but actually becoming virtuous in daily practice is the real challenge (and one that I don’t claim to have fully achieved).

There’s a Buddhist teaching, depicted above, that applies well to this crucial difference between the abstract knowledge of moral virtues versus their exercise: Imagine that someone is trying to show you the moon by pointing to it. One should not focus too much on the finger! With that caveat, following are some examples of how character is tested in the context of residency training; I hope that residents will find them to be useful pointers.

Humility. Neurology has become a very interdisciplinary field. Forget about the simplistic old saw that “The nurse can be your best friend or your worst enemy.” Today, we work with nurses, pharmacists, physical therapists, occupational therapists, speech/language pathologists, respiratory therapists, dietitians, social workers, case managers, etc., etc. Many of the above have graduate-level education, some doctorate-level. Most have years of experience—certainly more experience in their respective fields than a resident has in neurology. And regardless of age, each person is an expert in his or her area. I’m now PGY18 and have cared for thousands of stroke patients but I’m not as good at assessing the functional status of a stroke patient as my OT colleagues. And I’ll never be as good as they are, just like I’ll never read brain MRIs quite as well as our neuroradiology colleagues.

Therefore, when a nurse, therapist, pharmacist, or other member of the treatment team raises a concern or provides new information, it’s important to listen, consider the information on its merits, and integrate that into the case formulation. We must resist the urge to reject the information because it came from someone other than a physician (arrogance), because it doesn’t comport with our previous understanding of the patient’s condition (anchoring bias), or because acknowledging it would mean that we were wrong about something (denial).

That last point deserves emphasis: It’s OK to be wrong, as long as we remain open to correction! I know that doesn’t comport with our years of high school → college → medical school acculturation, where the point of the game, it often seemed, was to supply correct answers. But now we’re in a very different setting, where there are fewer right / wrong answers to be supplied and more assessments and plans to be made. EVERYBODY makes a sub-optimal judgment from time to time and it’s especially ridiculous to think that a PG2-4 neurology resident should be perfect in this regard. Our main mission is to take the best possible care of our patients. If there’s a piece of information or a perspective that might advance our patient’s care, we want to incorporate that as soon as is appropriate. And besides, resisting an opportunity to optimize a patient’s care or correct a mistake is much, much more injurious to a physician’s reputation than is the fact that he or she was once wrong about something. 

Honesty. Imagine a case1Perhaps this scenario seems too obvious or egregious to be true, but trust me—this kind of thing happens. where a patient presents to the ED one afternoon with a thunderclap headache and left-sided tingling. Exam is normal. CT shows no hemorrhage. CSF is colorless. Because of the focal symptoms and high-risk nature of the case, the patient stays in the ED’s observation area pending an MRI. The plan is to treat the pain, observe for some hours, and, if the clinical course and MRI/A/V are reassuring, discharge home with outpatient follow-up.

The next morning, the patient feels much better but the MRI still hasn’t been done. The ED resident informs you that the patient can only stay in the obs unit for a couple more hours—if more time is needed for the workup to be completed then he’ll need to be admitted. You make some phone calls and arrange for your patient’s MRI to be done next.

The ED resident calls again to report that the MRI is done and time is running out for an obs stay–a decision must be made now. You look at the MRI yourself (kudos!) and it looks OK. The prelim read is normal too. You call up your attending to explain that the patient is teed up for discharge, and he asks, “Do we have a final read on the MRI?”

Aaaargh! A final reading is going to take more time, and then you’ll be stuck admitting the patient only to discharge him a couple of hours later—a hassle for you both. And really, what’s the chance that the final read is going to be substantially different than the prelim? So, “Um, yeah, the MRI was read as normal,” you say. It’s sort of true, although not really. The patient goes home. And then the neuroradiology attending calls your attending a few hours later to report that they found a 2mm acomm aneurysm on the MRA. “Did that patient get discharged? We may need to bring him back . . .”

Always be honest—it’s best for the patient and, although it might not always seem that way in the moment, best for your reputation as well.

Kindness. It can be seemingly difficult to practice kindness while immersed in a challenging training program, or while running a busy clinical practice, or while managing a chaotic (e.g. child-rearing) household, or . . . you get the idea. But here’s a nice paradox: Being kind to your patient or colleague (or a family member, or perhaps especially to a stranger) is a reliable way to reduce both their suffering and yours.

And it can be really easy—I’m not talking about committing to 10 hours a week of volunteer work on top of everything else on your plate. Very simple things can go a long way: You took off the patient’s socks to check for Babinski’s sign? Put them back on. Carefully. Offer to cover her back up. Don’t forget to turn the TV back on if you turned it off. Did the nurse come in and silence the beeping IV while you assessed the patient? Thank him! Right then and there, in front of the patient. When the patient sees that you respect your colleagues, she’ll know that you respect her too. She will feel better about her care, and she will remember! She may not remember half the things you educated her about with respect to her stroke, but she *will* remember that you were kind. And once in a while, a patient will express to you, long after the fact and long after you’ve forgotten about it, her appreciation for that kindness. These are among the moments that sustain a medical career.

Obviously, this is a very limited list of virtues; please feel free to offer additional thoughts in the comments. I’d also be happy for interested residents to author guest posts. If nothing else, I hope this will get us thinking explicitly about the kind of physicians, and indeed the kind of people, we want to be.

Notes / References   [ + ]

1. Perhaps this scenario seems too obvious or egregious to be true, but trust me—this kind of thing happens.

About Justin A. Sattin

I’m a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.

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