Recapturing the Soul of Medicine

Rachel Naomi RemenIn the past 10 years, the culture of medicine in California has changed radically. A study of 454 clinicians by the Sacramento Medical Society indicated that most had felt the effects of these changes deeply1. Forty percent of those interviewed were clinically depressed. Most reported that they had thought about leaving the profession at least once in the past 12 months. Even more surprising, many would not want their children to go into medicine nor would they choose medicine as a career again.

This is not a California phenomenon. An unprecedented number of physicians nationwide, many of them young, are dropping out or seeking early retirement. Something unusual is happening among physicians, and those who care about physician well-being may need to broaden their concern from the care of impaired physicians to the care of all physicians. The future of our profession may be as stake.

There is reason to believe that our professionalism — our traditional professional stance, our attitudes, self-expectations, and indeed our training — has made us particularly vulnerable to the kind of stress we currently experience. Year after year in medical schools across the country, the first-year class enters filled with a sense of privilege and excitement about becoming doctors. Four years later, this excitement has given way to cynicism and numbness. By graduation, students seem to have learned what they have come to do but forgotten why they have come. In these times, we need to reconsider the principles by which we traditionally educate physicians. We will need to reexamine our educational goals, objectives, and strategies, to help students to stand up to the stresses of contemporary medical practice.

Finding meaning

Teaching the practice of medicine involves more than teaching its science. Medicine is in crisis, and in crisis we need to find something stronger than our science to hold on to, something more satisfying and sustaining to us as people in this work. Perhaps the answer lies in learning to cultivate the meaning of our work in the same way that we have traditionally pursued its knowledge base. We will need to learn to educate students to find meaning as skillfully as we educate them to pursue medical expertise.

In times of difficulty, meaning strengthens us not by changing our lives by transforming our experience of our lives, The Italian psychiatrist Roberto Assagioli tells a parable about 3 stone cutters building a cathedral in the Middle Ages. You approach the first man and ask him what he's doing. Angrily he turns to you and says, "Idiot! Use your eyes! They bring me a rock, I cut it into a block, they take it away, and they bring me another rock. I've been doing this since I was old enough to work, and I'm going to be doing it until the day that I die." Quickly you withdraw, go the next man, and ask him the same question. He smiles at you warmly and tells you, "I'm earning a living for my beloved family. With my wages I have built a home, there is food on our table, the children are growing strong." Moving on, you approach the third man with this same question. Pausing, he gives you a look of deep fulfillment and tells you, "I am building a great cathedral, a holy lighthouse where people lost in the dark can find their strength and remember their way. And it will stand for a thousand years!" Each of these men is doing the identical task. Finding a personal meaning in your work opens even the most routine of tasks to the dimension of satisfaction and even joy. We may need to recognize meaning for the resource it is and find ways to pursue it and preserve it.

Restoring a sense of service

Meaning is the antecedent of commitment, and the original meaning of our work is service. Service is not a relationship between an expert and a problem; it is a human relationship, a work of the heart and the soul. Restoring a sense of service to the practice of medicine will lead us to reexamine the process by which we become physicians. Our current training furthers our expertise but not our wholeness. We are trained to value objectivity. We are taught to view a genuine human connection as unprofessional. But we cannot serve or find meaning at a distance. Learning to serve requires education, not training. The root word of education, educari, means to lead forth the innate wholeness of each student. Medical training often wounds and diminishes us. Restoring a sense of service in our students will require fundamental educational reform.

As professionals, we may not be fully connected to our lives. Distance may become a daily habit. In reality, most physicians lead far more meaningful lives than they realize. Proust said, "The voyage of discovery lies not in seeking new vistas, but in having new eyes." Finding meaning will require us to see the familiar in new ways.

Harry, an emergency physician, tells a story about a woman who was brought into his emergency department about to give birth. As soon as he examined her, he realized that unless her obstetrician was already on his way, he was going to get to deliver this baby himself. He had barely finished his examination when the head crowned, and with nurses on either side of him holding the mother's legs on their shoulders, Harry delivered a little girl.

She was breathing spontaneously, and he felt a familiar sense of satisfaction at his own competence. He laid her along his left forearm with the back of her head in his left hand and began to suction her nose and mouth. Suddenly the infant opened her eyes and looked directly at him. In that instant, Harry realized that he was the first human being this baby girl had ever seen. Deeply moved, he felt his heart go out to her in welcome from all people everywhere, and for a moment he had tears in his eyes.

All this surprised him. Harry has delivered many babies and has always enjoyed the excitement of making rapid decisions and testing his skills. But he had never before let himself experience the meaning of what he was doing or let himself know what he was serving with his expertise. He feels changed by this moment. In that flash of recognition, he felt years of cynicism and fatigue fall away and remembered why he had chosen this work in the first place. As he put it, "It all suddenly seemed worth it."

Meaning is a human need. It strengthens us, not by numbing our pain or distracting us from our problems, or even by comforting us. It heals us by reminding us of our integrity, who we are, and what we stand for. It offers us a place from which to meet the challenges of life. Part of our responsibility as professionals is to fight for our sense of meaning — against fatigue and numbness, overwork, and unreasonable expectations — to find ways to strengthen it in ourselves and in each other. We will need to rebuild the medical system, not just on sound science or sound economics, but on the integrity of our commitment. It has become vital to remember the essential nature of this work and renew our sense of calling to preserve the meaning of the work for ourselves and for those who will follow.

1 Snider, M, Svenko D. The Physician Burnout Project. Sacramento, CA: El Dorado Sacramento Medical Society; January 1997.

This article was reprinted with the permission of the author and was originally published in the Western Journal of Medicine (wjm) and many not, save under fair dealing provisions, be reproduced without the consent of BMJ Publishing Inc.

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is medical director of the Commonweal Cancer Help Program, and a clinical professor of family and community medicine at the University of California San Francisco School of Medicine. Her books include My Grandfather's Blessings, and Kitchen Table Wisdom.