by Mick Krasner, MD
Who Are We?*
In many ways, choosing a career in medicine offers opportunities found in a few other professions. It can be described quite simply as the opportunity to work within one’s integrity. What I mean by this includes the possibilities of engaging through our work in activities that concretely improve people’s lives, relieve suffering, address inequities, and enact compassion. These opportunities flow from the values and ethics that are part of our human endowment, biologically reinforced through our capacity for empathy and the two-way experience of compassion. I was told by a faculty mentor during my residency, at a time that I was feeling very ineffective in my continuity clinic while working with some unsolvable medical and social problems involving a particular patient, that my interaction alone with this individual may be the only positive human communication they had that day or even within the current circumstances of their entire life. Contemplating that was reassuring to me and allowed me to feel a sense of calling and duty. Quite the opposite of the feeling of impotence and inadequacy that I felt then, at many moments during my training and since. It gave me a renewed desire to be thoughtful, kind, and as skillful as I could be, and to show up and be present, even in the face of my seeming ineffectiveness.
Many of my friends and acquaintances have chosen alternative career paths, people with intelligence, ambition, and even, from my knowledge, pro-social values. Yet many of those individuals have found themselves in work that can be characterized as falling outside of their integrity. The fact that they are skilled, excel in certain domains of knowledge, are ambitious, embody a sense of competition, and respond to the perceived cultural values and norms of success, along with the lure and excitement of power, have placed them now within professional settings that may be considered the opposite of pro-social and that contribute to many of the ills that our culture currently contends with. Reflecting on these pressures, some business community members recognize the sentiment that you can get so caught up in trying to win the game, that you do not ask yourself if it is the right game.
Medicine itself is embedded within this complex intersection, where working within our integrity and, at times outside of our integrity, creates challenging dilemmas. Most of us experience moral distress when we are unable, for systemic reasons, to do the right thing for our patients, colleagues, and staff. Many of us, indeed, have experienced moral injury from encountering these issues over and over. If we are introspective and honest enough with ourselves, all of us at a concrete level, are part of the system that creates and perpetuates a medical culture where moral distress is not an uncommon experience.
In a staggeringly powerful essay recently published in JAMA by a physician in training (who is also part of the Mindful Practice in Medicine community), Dr. Christian Archer reflects on how the environment within medicine, experienced as a trainee, has challenged his ability to uphold core values and beliefs. He points out many of the issues that contribute to this distress, among them: limited access to care; a focus on pharmaceuticals and procedures; a constriction of time with patients, which is sorely needed to educate and address behavior change; and cultural pressures to conform to lifestyle trends whose impact undermines health.
As I reflected on his article and considered the opportunities we have as physicians to work within our integrity, I was struck by one sentence in particular: Long-standing issues stemming from a culture that prioritizes market values and upholds a White-centered patriarchal power structure have contributed to a system increasingly incapable of providing adequate care for many patients. This prompted me to investigate, not only how my colleagues and I contribute to this dysfunction, but to also explore the desire to rediscover fundamental motivations that can begin to address the impact of these truths.
Dr. Archer is correct in asserting that resiliency training (dare I add) Mindful Practice in Medicine itself, are but “band-aids on a much deeper wound.” Yet, I believe that Mindful Practice can help us with the following: cultivate awareness collectively with an intention to accept honestly the true state of our medical system and our roles in creating it. It can help us maintain our integrity and capacity for curiosity and engage in authentic self-examination without judgment, but with compassion. We can learn through its practice to trust in the presence of our moral compass when we are allowed to view it free of outside influences. But most of all, it helps us build a healthier community – a professional community that is capable of uncoupling narrow self-interest with our manifest actions and supports each other in maintaining our integrity that is in alignment with our true calling in medicine. This can help us as a community address moral distress and moral injury, forces that threaten the potential of medicine and threaten the possibility of not experiencing the deep rewards that we all can share – physicians, patients, and our communities-by working within our integrity.
Archer, CA. Expanding moral injury: Why resilience training won’t fix it. JAMA. 2022; 328(12): 1199-1200. doi:10.1001/jama.2022.15721