“A Doctor Should Conclude His Life by Becoming a Philosopher?” Reflections on my Experiences in P-METaL

 From the March 3, 2023 issue of the Transformational Times

The issue focused on Kern Institute's "Philosophies of Medical Education Transformation Laboratory" (P-METaL). Dr. Yoon's essay served as the "Guest Director's Corner."

 

A Doctor Should Conclude His Life by Becoming a Philosopher?! Reflections on my Experiences in P-METaL 

 

 

John Yoon, MD    

 

“What does philosophy have to do with medicine?” 

“I’m philosophically challenged…I’m not sure this is for me…” 

“Plato and Aristotle? I don’t remember the last time I took a course in philosophy…” 

 

So full disclosure: I’m not a philosopher by training. I studiously avoided reading philosophy texts growing up. I don’t even recall taking a single philosophy class in college. All throughout my medical training, I watched copies of Plato and Aristotle collect dust on my bookshelf as they were squished between huge medical tomes like Harrison’s Principles of Internal Medicine and Robbins’ Pathologic Basis of Disease. And now nearly twenty years into clinical practice, I can’t exactly name a moment when I completed a module of Continuing Medical Education (CME) that connected the relevance of philosophy to medicine in any meaningful fashion. The sentiments listed at the beginning of this essay are ones I’ve heard expressed by my fellow colleagues over the years, and yet they represent genuine feelings I’ve had over the course of my own medical career.  

 

 

How then do I find myself working in a Philosophies of Medical Education Transformation Laboratory (P-METaL)? 

 

Granted, I sometimes experience symptoms of “imposter syndrome” being around such thoughtful and philosophically minded colleagues, but I have to say that I’m loving it! My journey to P-METaL started nearly two decades ago: At some point in the middle of my grueling internal medicine residency training, I was taking a brief break in my cramped call room to ask myself a nagging and somewhat uncomfortable question:  

 

“Am I truly becoming a good physician?” 

 

And I realize now that I wasn’t simply asking the question of whether I was becoming a clinically competent one; I was asking myself whether I was becoming an ethically excellent one. On one hand, I was comforting myself with the thought that my residency program leaders and the ACGME were making sure that the former was going to be true by the time I finished residency training. Yet I wasn’t exactly sure about the latter—was I becoming the good physician consistent not only with the profession’s ethical codes but also with my own personal moral aspirations?1 Or to put it another way, was I becoming a morally admirable physician that Mama would be proud of? 

 

As I look back, this existential angst launched me on my own scholarly journey—the kind of journey where one pursues scholarly activity as a therapeutic intervention for a kind of “existential burnout.” And as I waded through papers and articles from the Bioethics/Clinical Ethics literature, the Professionalism/Medical Humanities literature, and even the Physician Well-Being/”Finding Joy in Medicine” literature, I began to realize that what I was feeling in isolation was being felt all throughout the profession; hence the move toward “Good Physician” movements in medicine like ethics, professionalism, humanism, and wellness.  

For example, while undergoing my “therapy” in the Bioethics and Clinical Ethics literature, it occurred to me that much of what my clinical ethics training was trying to do for me could be re-conceptualized as cultivating the virtue of “practical wisdom,” or what Aristotle called phronesis. As my existential burnout began to subside a bit, my “therapy” progressed to the Professionalism and Medical Humanities literature, where authors were collectively inspiring me toward the noblest of human activity while practicing medicine—a move toward what had been classically conceived as character development or virtue formation (arete). And lastly, as my therapeutic remedy for existential burnout prescribed a heavy dose of literature on Physician Well-Being and “Finding Joy and Meaning in Medicine,” I could not help but wonder if this movement was recovering—in fits and starts—a deeper understanding of what it means for human beings holistically to flourish (eudaimonia). 

And as was suggested in a previous Kern Transformational Times issue, it occurred to me over time that contemporary movements in medical education seem to be addressing universal human realities that are not actually all that new—and that philosophers have already had something important to say about these human realities for centuries. As a result, it seemed to me that my fellow medical educators and I were only finding ourselves reinventing the proverbial [philosophical] wheel, unwittingly retrieving a foundational idea that was already articulated somewhere at some time—by a philosopher.  

So, I developed a working hypothesis: contemporary movements in medical education were all actually connected together in some way. And that the philosophical framework that could have connected these various movements together had long been lost but was now undergoing a reawakening in philosophical circles—the philosophical framework of virtue ethics. And so this journey to seek healing from my “existential burnout” has led me to my new academic “recovery house”: P-METaL and the Kern Institute. Here I’ve been privileged to explore what a contemporary retrieval of a virtue-based framework might do to unite and integrate some of these major trends in medical education. Here at P-METaL, I get to work with thoughtful colleagues who hope to lay a solid conceptual foundation for thinking about how to navigate transformation in medical education for the 21st century. P-METaL has infused a new “Why” behind my work as a physician and medical educator. 

I guess you can also say that I’m experiencing what you might call “a coming to the [philosophical] light”—a conversion of sorts. A conversion that gives me a new way of “seeing” the world of medicine. A conversion that makes me wish I paid more attention to my humanities college professors, particularly as I sit in awe over the transformative influence that philosophers have made over the course of history through the power of clarifying and articulating a foundational idea.  

 

The power of conceptual clarity for medical education transformation 

One foundational idea that presently grips me is one that I’m learning from my philosopher colleague Dr. Fabrice Jotterand, Director of P-METaL. Extending the work of physician-philosopher Edmund Pellegrino, Dr. Jotterand puts forth this foundational idea in medical education of helping medical students and trainees cultivate a personal moral philosophy of clinical practice.2 As a medical educator in ethics, I often encourage students not to neglect their “moral compass” as they move through the formal and hidden curriculum of medicine. And yet offering that specific counsel to students in a didactic ethics lecture does not seem to be all that sufficient, given what we know of the “hidden curriculum” and the formative power of institutional culture and profound social forces in health care. Jon Tilburt and Gail Geller further observe:  

“The culture of academic medicine holds implicit and explicit assumptions about what is important in life, including assumptions about health and the practice of medicine. This philosophy of life constitutes a worldview from which medicine is practiced.” 3 

They further note along these lines that foundational assumptions like the ones encompassed in the dominant biomedical worldview have too often “dismissed other important perspectives on life in the quest for lifesaving discovery.” 3 

So when we help our students trainees develop a personal moral philosophy of clinical practice, we help them “see” the world of medicine with hard-edged reality, but we also encourage them to cling to those other important personal and professional perspectives on life that go beyond (and sometimes not welcomed by) the dominant biomedical worldview of contemporary medicine. 

 

Therefore, what our students need is not simply the glib counsel to follow their moral compass; we need to assist them as medical educators to construct a moral map as they navigate their way through the moral hazards in medicine. A moral compass might point you in the general direction through the guidance of a north star; but you still need a map to navigate your way to your destination while avoiding “lions, tigers, and bears” along the way. A personal moral philosophy of clinical practice might offer that integrated personal/professional moral map for students’ careers in medicine—not necessarily as a step-by-step, rules-based, “how-to” instruction manual—but more as a content-filled, motivational framework for how one might approach decisions with practical wisdom (phronesis). This personal moral philosophy of clinical practice would aim for the good of the patient while preserving one’s own sense of integrity as a practicing clinician. Helping medical students and trainees develop this kind of conceptual clarity in their own lives might be one step toward immunizing them against the kind of “existential burnout” that I described earlier in this essay. 

 

 

My hope to cultivate good soil for medical education transformation through P-METaL 

 

My time in P-METaL so far has helped me deeply appreciate the contributions of my more philosophically inclined colleagues. But sadly, throughout academic medicine and even in my own institution, the work of philosophy sometimes comes across as “clinically irrelevant,” “overly abstract,” and not “RVU-generating.” I like to respond by saying that everybody likes to enjoy the delicious fruit from healthy, growing trees but no one ever wants to spend time looking deep into the soil that makes them grow well. What you see visibly growing on the branches of a flourishing (or languishing) tree perhaps tells you more about the quality of the soil that it is rooted in. Likewise, as we seek to transform medical education to promote foundational ideas like character, caring, practical wisdom, and human flourishing, I can’t help but probe deeper into the soil of medical education and ask myself questions like: 

 

“What are the rooted foundational ideas driving our theories of cultural change in medical education?”  

 

“What foundational ideas are informing our pedagogies and policies in medical schools, residency programs, and academic medical centers—and what do these foundational ideas reveal about our hidden assumptions about what it means to flourish as human beings?”  

 

“What can we do to ensure that all our bold initiatives to transform medical education are not only educationally feasible and clinically relevant, but also philosophically grounded?” 

 

Together with my P-METaL colleagues, these are the kinds of questions that I’ve enjoyed exploring through my role in P-METaL. We explore such questions as we assist in local curricular renewal efforts (MCWFusion) through P-COACHING for Medical Education—a consultation service described in greater detail by Dr. Jotterand in a separate article within this Issue. And later next month, P-METaL is hosting its inaugural Visiting Professorship—an exciting series of discussions at MCW that will feature an influential thought leader at the intersection of philosophy and medical education, Dean James Woodruff (The University of Chicago Pritzker School of Medicine).4-5 

I should also note that we have now started to explore these kinds of questions in national forums like the Academy of Professionalism in Health Care (Oct 2021) and the Kern National Network Conference (Sept 2022), where there we presented a discussion panel featuring local MCW clinical and bioethics faculty: “What is Gained When We Teach Principles of Evidence-Base Medicine and Skills of Diagnostic Reasoning Within the Philosophical Framework of Practical Wisdom?” (Dr. Jayshil Patel, Dr. Michael Putman & Dr. Fabrice Jotterand). Building upon these initial discussions, we are now excited to propose another panel discussion at the next AAMC: “What role does philosophy have in the day-to-day work of medical education? A panel discussion exploring philosophical foundations for medical education reform.” Through these national forums, we hope to convey the importance of philosophical integration in any meaningful effort for medical education reform. 

Lastly, I’ve been personally encouraged to see that the Kern National Network for Flourishing has been hosting online Book Clubs that strategically highlight key philosophical concepts such as practical wisdom (phronesis), thus providing a national online forum to explore philosophy’s contemporary relevance for flourishing in health care. So all in all, when it comes to integrating the insights of philosophy back into medicine, winds of change are indeed blowing.  

 

In closing, I guess you can say that because of my involvement in P-METaL, I am glad to report that I am starting to take those old dusty philosophy books off my bookshelf again. And thanks to the help of some capable guides,6-7 I am discovering a new love for a field that, in retrospect, should have been my college major if I had to do it over again. And so next to earning my annual CME credit, my RPE (Remedial Philosophical Education) continues in earnest. Time will tell whether that ancient Greek saying ends up being fulfilled in my life: 

“A doctor has opportunities for studying human nature which are given to no one else, wherefore a philosopher ought to begin his life as a doctor, and a doctor should conclude his life by becoming a philosopher.”    

 

In the meantime…Plato and Aristotle book club anyone? 

 

 

For further reading: 

1. DT Kim, MK Applewhite, W Shelton. 2023 [under review]. Professional identity formation in medical education: Some virtue-based insights. 
2. Jotterand F, Derse AR, Spellecy R, Stawski C, Kalet A. 2023 [under review]. Practical wisdom, clinical judgments and the agential view.  
3. Tilburt, Jon, and Gail Geller. "The importance of worldviews for medical education." Academic Medicine 82.8 (2007): 819-822. 
4. Woodruff JN, Lee WW, Vela M, Davidson AI. Beyond compliance: Growth as the guiding value in undergraduate medical education. Acad Med. 2023 Feb 21:e005190. doi: 10.1097/ACM.0000000000005190. Epub ahead of print. PMID: 36811974. 
5. Woodruff JN. Accounting for complexity in medical education: a model of adaptive behaviour in medicine. Med Educ. 2019;53(9):861–73. 
6. Stumpf, Andrew. Ancient Philosophy: A Companion to the Core Readings. Broadview Press, 2018. 
7. Pellegrino ED. The philosophy of medicine reborn: a Pellegrino reader (HT Engelhardt Jr, F. Jotterand, eds). Notre Dame, IN: University of Notre Dame Press; 2008. 

 

John D. Yoon, MD is Visiting Scholar at the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education where he serves as a member of the Philosophies of Medical Education Transformation Laboratory (P-METaL). He is also an academic hospitalist and Director of the Program on Medicine and Religion at the University of Chicago.  

Email contact: jyoon@mcw.edu