Physician Distinguish Thyself: Conflict and Covenant in a Physician's Moral Development

PHYSICIAN DISTINGUISH THYSELF: CONFLICT AND COVENANT IN A PHYSICIAN'S MORAL DEVELOPMENT DAVID A. LANDIS* There comes a time in the education of physicians when students become willing to accept the title "doctor." This change has little to do with their technical or cognitive competence. Rather, it comes about when they reconcile themselves to the role of physician and its many burdens, not the least of which is the emotional toll of caring for patients . The task of learning the affective skills needed to practice medicine well is complicated by the fact that cultivating appropriate behaviors and reactions can have detrimental effects on medical students' personal lives. Students and doctors need to be able to conceive of their obligations to patients in such a way that, by fulfilling them, they do not compromise their own personal health or happiness. In this paper, I argue that this can be done if they understand their identity as physicians as being born out of a covenant made with the profession of medicine . Conflict: Affective Skills in Medical Education In the preclinical years of medical school, educators convey to students the importance of the cognitive information and skills required by doctors. Indeed, the belief that these are all that a good doctor needs is pervasive [1, ch. 5 & 6]. Yet, when students enter the world of clinical medicine during their third-year clerkships, they discover significant emotional and moral challenges. They discover that, as doctors, they The author expresses gratitude to his teacher, Peter Williams; to his editor, Jack Coulehan ; and to his mentor, Eric J. Cassell. This paper was written while the author was the Student Fellow at the Institute for Medicine in Contemporary Society, State University of New York at Stony Brook. He is currently a fourth-year medical student at the School of Medicine, S.U.N.Y. at Stony Brook, New York.»Address: 23A Four Winds Road, Setauket, New York 11733.© 1993 by The University of Chicago. All rights reserved. 0031-5982/93/3604-0826$01.00 628 David A. Landis ¦ A Physician's Moral Development must routinely inflict pain in order to help their patients. Students encounter the difficulty of enduring not only the nauseating sights and smells of the hospital, but also the uncertainty that is an inevitable part of patient care decisions. Early clinical experience impresses upon students that in order to be good physicians they require not only cognitive, but also affective skills. In remarkably little time, most students seem to possess the required affective skills and are able to demonstrate a professional demeanor. This success comes at a cost, however, because the skills utilized on the wards are not shed as easily as a white coat. Having protected themselves from the suffering and pain of patients, students can become unable to respond to the affective world outside of medicine. The pervasiveness of the new medical disposition is first revealed, perhaps, when students notice themselves estimating on the subway how easy it would be to get blood from this or that person's arm [2]. Soon, students become immune to the suffering of the homeless they pass; or, they shrug off the death of an uncle. The message is complete when they notice—or more likely are informed—that they treat the concerns and complaints of loved ones with the same clinical detachment that they do those of their patients . Thus, the mastery of the affective skills needed to practice medicine can be detrimental to a student's personal life. A concern for the personal hazards inherent in doctoring has a long history and is reflected in many codes of medical ethics, from the Hippocratic Oath to the most recent. The prohibitions against sexual relations with patients or violations of confidentiality acknowledge the tension that exists between physicians' professional responsibility and their private inclinations. Our tradition similarly recognizes that the need continually to mediate this tension poses a personal or psychological risk to doctors. This risk is illustrated by the doctors in the plays of Anton Chekhov. Chekhov, himself a physician, writes of doctors who "struggle in the face of defeat to remain connected to life, and they describe the temptation to avoid suffering by becoming invulnerable...