4.1 - Physician Identity and Formation with Ben Frush and Brewer Eberly

What does the ideal physician look like? How do we get there? What influences our identity as physicians as we go through training? Where do we look for guidance in this journey? Join us as we delve into the personal journeys of our guests, examine the concept of "professionalism," and explore the ideal physician, including the role of the moral and spiritual dimensions in medical practice. Our discussion touches on the historical and cultural factors that have contributed to the evolution of the modern physician as well as the challenges of cultivating a deeper sense of meaning in medicine.

52 minutes • Published Jan 13, 2025 • Download • Transcript

Recommended readings

Berger, P. L. The homeless mind. 1973
Bishop, J. P. The anticipatory corpse. 2011
Buchanan, M. The rest of God. 2007
Hauerwas, S. Suffering presence. 1986
Kinghorn, W. A. Medical education as moral formation. 2010
Kinghorn, W. A., McEvoy, M. D., Michel, A., & Balboni, M. The emperor has no clothes. 2007
Kinghorn, W. A. Against the Moral/Medical Divide. 2024
Marti-Ibáñez, F. To be a doctor. 1960
May, W. F. The physician's covenant. 1983
McKenney, G. P. (Ed.). To relieve the human condition. 1997
Pellegrino, E. D., & Thomasma, D. C. The practice of medicine. 1981
Optimal Work, Kevin Majeres
Theology, Medicine, and Culture Initiative

Transcript

[Intro music]

Hi and welcome to the Hippocratic Society Podcast. This podcast is a project of the Hippocratic Society.

In the podcast, we aim to reflect on deeper questions in medicine, all with the aim of rediscovering the ideals that brought us to medicine in the first place in order to better serve our patients and colleagues.

Thank you for joining us and we look forward to engaging with you through this podcast.

Hi and welcome to the Hippocratic Society Podcast where we aim to help physicians and trainees thrive by giving them the tools to pursue and practice good medicine.

My name is Michael Egan and I am joined today by Dr. John Rhee, Dr. Benjamin Frush, and Dr. Brewer Eberly.

Dr. Rhee is a board certified neurologist, neuro-oncologist and palliative care specialist at Dana-Farber Cancer Institute and instructor of Neurology at Harvard Medical School.

He is a young member of the Pontifical Academy of Life and co founded the Hippocratic Society as well as serving as its Vice Chair and executive director.

Dr. Frush is trained in internal medicine, pediatrics and palliative care.

He is currently a McDonald Agape Fellow in Bioethics at Georgetown University.

And Dr. Eberly is a family physician working at Fisher Clinic in Raleigh, North Carolina.

A physician, artist and writer, Brewer's work has been published widely from clinical journals such as JAMA and Chest, to periodicals like the New Atlantis, Christianity Today, and Plow.

Thank you all very much for joining us on the show today. It is an honor and pleasure to have you here and I'm very excited for the discussion today.

Thank you, Michael.

Yeah, thank you for having both of us. We're excited to be here.

Yeah, thank you.

Great. So today we're dealing with an important topic, physician identity and professional formation.

Before we get started, as we are talking about physician identity information,

I'd like to hear a bit from each of you about your own physician identity and formation and your medical journey. Because as I understand it, that could be very helpful in framing our conversation here today.

Yeah,

this is Ben. I'll start. So I grew up in a home where both my parents are were physicians and I think set a really positive example for me of what medicine, a career in medicine could look like.

And they both very much enjoyed their work and I think enjoyed the experience of being able to directly help take care of people in need and grow and learn science and technical aspects of the job.

And for both my parents, it was a way to fulfill their vocation as as Christians.

In my journey,

I went to medical school at University of North Carolina, where I had a very positive experience.

Different mentors and role models who I think set really powerful examples for me specifically in their work and caring for the marginalized and vulnerable. UNC as an institution with a goal for serving the people of North Carolina and oftentimes is tasked with taking care of those patients who can't really receive care elsewhere.

And then during medical school, I took a year off and studied at Duke Divinity School where I was a Theology, Medicine and Culture fellow, which is where I met Brewer.

And it was that experience that was really, really transformative for me in the way that I thought about medicine as a profession and my place in it.

My time as a TMT fellow and what we read and the conversations that we shared allowed me to understand medicine as a vocation that was not only technical and informational in nature, but moral insofar as it requires virtue to be done well.

The inherent vulnerability of sick patients seeking out care of physicians requires that physicians not only know how to practice medicine well clinically, but also inhabit and demonstrate virtues like patience, compassion, self effacement.

And the TMC program gave me a new vocabulary to use in describing and thinking about my work in a community of similar trainees and mentors to discuss some of the challenges of training and my hope for what it might look like one day to be a physician caring for patients.

And then I did my residency at Vanderbilt,

which was a great training experience.

And I think the experience of residency really brought to the fore and tested some of the ideas that I had been exposed to in medical school and divinity school about what it meant to be a, an excellent physician, again, not only from a strictly clinical perspective with diagnosis and decision making and treatment,

but also what it meant to be somebody who demonstrated compassion and courage amidst the challenges of training,

but also sought to try to attend to the needs of the people that I was working alongside, fellow trainees and students and co laborers.

So throughout my medical training, I was able to maintain a lot of the friendships that I had developed at the Theology, Medicine Culture Program and friends from medical school to constantly talk about these challenges and, and what it meant and looked like to practice medicine well and to even flourish amidst some of the well characterized challenges of training that Brewer and I will discuss later.

And now, and you know, working as an attending, I'm grappling with what that looks like to no longer be a trainee, but somebody who practices, you know, independently and supervises others and still thinking about what it means to be a professional and the ongoing process of being formed in that.

That image that I've come to come to understand.

Yeah. Similar to lots of similarities with Ben's

story, and it's fun to hear it again.

I also grew up in a medical family. My father was a family physician, is a practicing family physician still.

My mom was a nurse.

My dad's dad, my grandfather, was also a family doc, one of the first in the profession, split off from Internal Medicine in 1969.

His wife was a nurse. My uncle's a cardiologist. His wife also a nurse,

my cousin's pediatrician. So was just always in the.

The blood from the beginning,

listening to the ways that my grandfather, my dad, and my uncle especially talked about the care of their patients. And the way they talked about it was utterly attractive and winsome.

So even from elementary school and high school on, I longed to understand and witness the kinds of things they were talking about.

And in particular in high school, just,

it seemed to me that medicine was this place for the things that most mattered in life. The questions about birth and death and sex and suffering and the things that humans spend most of their lives interacting with or struggling with.

Medicine was there and willing to engage at the same time. My mom's side of the family,

my mom's mom, my grandmother was a stained glass artist and a painter.

My mom's father,

not in medicine, but always longed to be in medicine but couldn't afford it and spent his life caring for the poor in rural Tennessee.

And so I think my formation was absolutely bound up in the confluence of all three of those worlds. My,

on the one hand, medical family,

but on the other side, this quieter inheritance of the arts and kind of this quieter sense of the vulnerable and what it might mean to dedicate your life to looking at wounded places and also being willing to engage the beautiful to do so, which is also something we'll talk about a bit later,

about the role of the arts and the beautiful in physician formation.

So I went to medical school.

Unlike Ben, I really struggled with it. I thought about leaving medical school because of the misanthropy and cynicism and disillusionment and aspects of the hidden curriculum. I discovered behind the scenes.

I was not a good student for that reason and just didn't have my heart in it.

Reached out to the theology, medicine and culture folks and asked if I could apply to study with them. And that's where I met Ben, who's become a dear friend and someone I delight to think with and write with.

And, you know, this isn't a podcast about the tmc and the Theology Medicine Culture initiative. But it absolutely changed my life and gave me a community and a new way to see and hear within medicine is what I would say that I took with me back to medical school as a fourth year med student,

where I started a project called Phronesis, which is a forum for medical student formation,

where I invited students to gather together in a brewery coffee shop and asked the big questions of medical training that we sensed were not being asked throughout the course of medical school.

Even the question of what is medicine? For such a simple question that I had not experienced being asked and through the TMC had discovered how important that question is,

went to residency and still had that love of trying to gather souls around difficult questions that weren't being asked. And so had a hand in trying to start some small kind of resident conference sessions on big questions in bioethics, but with our feet always rooted in the daily practices of residents in training.

Now I'm a family doc about two years into practice, and what I would say is the questions that became fascinating to me seven years ago have only become more important and more tangible, even on the ground of what medicine is for.

What are we doing here again? What kinds of physicians are we becoming?

How are we thinking about the next generation of doctors and students in residents and who they're going to become?

What does it mean to continue to be formed in other moral communities that shape us and give us an orientation and a sense of a hope and a future?

So already saying too much. And it's, it's great to talk with you all and. Yeah,

great.

Well,

even touching on some of the brief things that you guys have been through, it's clear that you have a profound formation as physicians and as humans. And I can't wait to hear more about that.

So there are plenty of buzzwords that get thrown around all the time when it comes to identity and professional formation.

And at some point they seem to have become meaningless words like professionalism, identity formation, humanism, et cetera. So just to kind of get everyone on the same page,

what are we talking about when we say physician identity and professional formation? What exactly do we mean?

I'll say, personally, I approach this question of,

from a sense of if you asked a training resident today, they probably would struggle to even know what you're talking about, which, which actually might be part of the problem.

When I asked medical students how they understood their formation, one of the first questions I got back was, are you talking about like uterine malformation, like in the womb, like that The Mind just immediately went to clinical context and pathology, which in some sense is actually a very fitting metaphor because the place of medical training can often not be a healthy place to grow or to flourish.

So I don't know that I. We. I know that I personally can offer a strict definition, but what I would say is physician formation is the way to begin thinking about the forces that shape us into the persons and practitioners we are and are going to continue to become.

It's a way of having eyes to see that there are moral assumptions, moral communities,

metaphysical assumptions that undergird the way that we come into the spaces of training.

But then there are also metaphysical pressures and assumptions that shape and constrain us just through the process of going through training.

It's kind of like a plant that you put into a pot. The roots are going to fill whatever available space is there.

Or if you imagine a tree inside a greenhouse where most of the panels are painted over, only a few panels are open to the sunlight, that tree is going to grow and kind of constrain itself to reach the light.

And in medical training in general,

the kinds of formation that are rewarded, the kinds of identity that are rewarded, are academic and scholar and industrial, efficient,

clinical diagnostic worker.

And so that often becomes the kind of identity that we're formed into.

Primarily one of worker, primarily one of efficient, competent worker, perhaps with some compassion in there.

So maybe I'll stop there. Maybe that's actually a place we can kind of explore and talk about together. Is a strict definition helpful for the very question,

or does it press on the need for moral clarity on what it is we're doing here and who we're becoming?

I think what Brewer and I, because we've talked about this question a lot, would probably try to emphasize when it comes to the topic of professional identity formation or for physician formation,

we tend in our writing and talking to use the term moral formation to emphasize the point that, you know, medicine is inherently a moral practice, and the process of learning to become a physician is one that is intrinsically bound up with what it means to be a good person.

Not, not merely good in an effective or technical sense, but morally excellent and. And more of an Aristotelian framework of understanding the good life as entailing both excellent at one's craft, but also moral excellence or flourishing.

And I think one of the challenges with the language of professionalism or professional identity formation that we would critique, and I think I speak for Brewer here, is an idea that one of our mentors, Warren Kinghorn, has explored before,

of the tendency with, within medicine to understand everything from a mechanistic and a. A technical frame of view.

And so Warren has wrote a great essay several years ago now about how the notion of professionalism in medicine has become sort of an Aristotelian techne,

or idea of, of a technical undertaking, rather than something that deals with what it means to be, you know, a flourishing moral agent.

Oftentimes when we hear professionalism invoked in medicine, medical training, it's primarily in the context of things to avoid.

I hear the term like the threat of unprofessional a lot more than I hear the term professional kind of doled out. And I think that's because we oftentimes struggle to articulate clearly what it means to be an excellent physician.

What it means because that presses upon questions of ultimate meaning and purpose and telos that sometimes can engender disagreement,

whereas it can be easier to point to the deficiencies or things that we think are going wrong using the sort of threatening moniker of unprofessional.

So that's another roundabout way of arriving at the point that I think medicine actually struggles to offer a robust sense of what professionalism entails.

But Brewer and I both understand the formation process of a physician as something that involves what it means to become a better person in the course of caring for others within a moral community that helps lend clarity as to what better and worse look like.

Yeah, I totally agree. And what's coming to mind is a conversation I had several years ago about how professionalism,

the way it's often taught, is something like show up on time, well groomed, well dressed, and you know, make sure your epic in basket is empty at the end of the day.

And so professionalism gets cut down to this very week.

Not inspiring,

not morally elevating.

Yeah, techne oriented towards the efficient running of a. Of an industrial complex.

But if professionalism, if what we mean by that word is something living and active,

I mean, it's in the word itself that it's professing something, it's claiming to have a sense of the good around which we should orient our lives and work,

then it, it begs for this richer conversation about what it is we're doing.

I think anyone can.

This, this might be a bit too crude way to put it, but anyone can slap a few bullet points on a PowerPoint slide and say this is what it means to be a professional doctor.

But professionalism is the kind of thing that is made known in community, is oriented in communities towards an end.

It's known in the care of the suffering other.

And I think it actually speaks to why consensus on this question is so difficult to achieve today. Back to that King Horn article, the emperor has no clothes.

Professionalism in modern medicine.

I think it's also one of the reasons we don't take oaths today in the old way that we once did,

precisely because there is no consensus.

So you have students writing their own oaths, or you have consensus statements that are produced by alternate communities of practice on what they would say is the goal of good medicine.

Yeah, thanks so much, Brewer and Ben and I wanted to bring the listeners back to some of the themes that we talk about in the Hippocratic Society, which is this idea of the pursuit of the good, right and information.

A well formed person in medicine is not he who always does the right thing, or even less he who always conforms to good rules of behavior,

but rather that well formed person is someone who is good.

Right. Because there are many reasons for acting, including duty, or someone says so, or I have to,

but there is this really human aspect of doing things because I freely want to.

And there's a sense in which talking about the good that we are pursuing in medicine is also closely tied to this idea of freedom, which is very core to what it means to be human.

And also this idea of what it means to form people being, not just learning concepts or ideas of how our life ought to be,

but rather to form is to give form. So it's not just adding color or glazing over, but giving the essence of form. Right. It's not about appearances, but about being.

And I think that these are important concepts that we try to talk about in the Hippocratic Society. This idea of what is the pursuit of the good, what is the good in medicine that we are trying to pursue?

And also that importance of doing things in community,

pursuing that in community, which both you touched on now in the concept and the discussion about moral formation in medicine, but also comes clearly through in your journeys in developing into the physician that you are today, and also the continued development into the physicians that you want to continue and to become

all that extremely helpful. And it seems to me that the idea of becoming a physician, of being formed into a physician,

really hinges on the idea of what a physician is. And so I think that's a natural transition into the next question of who or what is this ideal physician? Who are we looking to form people to be?

What is, what are the aspects that contribute to the identity of a physician?

I'll jump in here. I mean, in part Actually, to comment very briefly on what you.

On what you just said, John,

that you're making me think of Felix Martin Ebenez. He's a. He was a psychiatrist, historian. He wrote this little book called To Be a Doctor that had a profound impact on me.

My grandfather gave a copy to my dad, who gave a copy to me. And then when my grandfather died in medical school, my dad,

like, re. Channeled his voice in this letter that he had given to him and kind of gave that to me that draws on this tiny little red book. But he ends his.

His little essay, to be a Doctor with this claim about professionalism where he says, be what thou art.

It's Pindar's theme, and it's. It's one of those statements that, you know, you're like, be what thou like. I guess I just. Guess I'll just be who I am right now.

But what he means is be what you are, which is a young doctor. Be a physician. And it just immediately begs the question of what a physician is,

what a physician does. You know,

so even in that little. That little book, that little idea that professionalism,

immediately you must. Must ask these questions of who you are trying to be, what it is you're actually doing,

what it is we're called to do.

I'll.

I'll.

I'll say briefly that this question of who's the ideal physician and what does it mean to be a good doctor?

I mean, it's. Look. I mean, it's terrifying to answer, right, Because I'm only two years outside of training, and so I'm haunted, I think, by the need for humility and slowness to speak.

So, pardon me as I'm trying to choose my words carefully here, but I think what I can tell you after two years of practice is that what helps me think about answering this question is imagining one of my loved ones,

my son or my wife,

one of my sons in a hospital bed. Who. Who do I. Which is not a pleasant thing to imagine, obviously.

Who do I want to walk into that room?

What. What would mark that person?

What would mark their character? What would mark their forms of practice,

have been helpful orienting questions for me about, as I consider suffering, people that are close to me,

and therefore, am I.

Am I becoming more and more closely aligned with that ideal vision of the person that I would be, I would long to be caring for my loved one.

This. This is. Connects to William May's great book, the Physician's Covenant, Images of the Healer and Medical Ethics that Ben and I've Both read for Paul Ramsey.

You know, he has this powerful claim that ultimately it's only the patient and their loved ones who can claim what good has been done, what type of heroism has been done on their behalf by their physicians.

That doesn't mean we can't say and claim specific things just to make the point that there are some forms of excellence that are only known through the care of the suffering other that make it known what it is we're doing and what.

And what we should be doing.

I don't have too much to add there. It's always hard to follow. Brewer.

The thing that I'll emphasize is that with our sort of description of moral formation of medicine as something that draws on virtue and requires sound moral formation,

I think it lends to the potential air of,

of like bifurcating or dividing what a physician does between the strictly clinical and technical and the sort of moral, virtuous and ethics related side of the work.

Stanley Hauerwas, who's a theologian in an essay,

I think the title is something like Suffering Presence. Maybe that's the title of the book of essays. But he, he says, I take the, the constitutive role of the physician to be someone who offers presence in the face of pain,

of suffering, which is incredibly powerful. And as a palliative care trained clinician, I think resonates very strongly.

The thing that I'll say is I think that's an insufficient definition. Right. I think that is necessary, but not totally explanatory. What the physician does.

Excellence as a physician entails both the compassionate and self effacing characteristic of the clinician. It also entails rigorous training and thought,

clinical and technical excellence.

It can't be reduced to either of those two modes.

And excellence in both of those realms is difficult to achieve.

But I think we have to resist the sort of distinction between those two. Again, this is something Warren King Warren has written about recently as well, the tendency to divide the moral and the medical.

But I think the excellent physician is one who embodies all of those practical virtues,

both clinical and moral.

Yeah, I love those reflections that both of you are sharing. And Brewer, one of the things that you mentioned about this image of somebody you love being in the hospital bed and then using that to inform what an ideal physician looks like.

I think it's very interesting because it again ties back into the things that we talk about in the Hippocratic Society. The idea of what are our ideals that we pursue and also having an idea of what that good is, what that ideal is is helpful in us then seeing how to get there or how to pursue those ideals,

right. Becoming that person that we want to become.

And I like to kind of bring that back to this idea of formation which Ben brought up,

this idea that again,

to be formed is to be in stable conditions, to act well.

And what forms us are those stable qualities, those virtues,

which when we acquire them,

they transform us, they transform who we are.

And so for the well formed person, that good comes naturally.

So it's not just wanting to do good things, but being good itself.

And there's a sense in which formation should always be presented,

as we try to do here, as an ideal,

because ideals are beautiful. And so when we think about that ideal physician,

when our family member is sick,

there are aspects in which we are pursuing something very beautiful in that practice of medicine.

Now, John, I was just gonna say, I would love to pick your brain on the language of ideals. And if you've encountered any skepticism about that language,

as beautiful as it is, and thinking about that To Be a Doctor essay I mentioned,

he orients that entire essay around ideals and is very willing to engage them as a goal. But it seems like we inhabit a kind of time in which we're very practically oriented, very efficiency oriented,

in which the language of ideal, like I can just imagine colleagues and friends from residency saying,

yeah, look, ideals are great, but like, we got to live here on the ground and,

you know,

how do you interact with that?

Yeah, I think it's a great question.

A lot of the use of the word ideals, I actually draw from the work of a psychiatrist, Dr. Kevin Majors, who does this work called optimal work. But it's the idea that virtues, I think,

have a long history and tradition and helps us understand,

perhaps in a very specific context of what we mean when we talk about virtues. But in today's world, that might be a little bit less accessible to people because it comes from a particular,

let's say, philosophical tradition that perhaps people these days are not as familiar with.

The reason why I like the word ideals is because I think it draws our minds and hearts to this idea of greatness which you're talking about. Brewer And I personally think that that's what our culture and our society needs today, especially in medicine.

There's a sense in which ideals seem unending in terms of the heights in which we could reach for a particular ideal, whether that be love,

generosity, a sense of service for others, a desire to give ourselves for others, we could always grow in them. And just the word ideal tends to seem like it's something soaring above us.

And I think that all of us.

Well, this is, you know, my, My understanding of, of anthropology, of. Of what we are made for. But I think we are drawn to when we allow our hearts to be open to it,

to things that are our high ideals, things that are beautiful,

things that give us awe. Right. And I think sometimes the cynicism pulls us down,

but in our culture, where we are often encountered,

where we're often encountering a lot of that cynicism in our daily life,

that which helps us escape from that are high ideals.

Yeah, that's beautiful.

Yeah, I agree.

Thank you.

Yeah, thank you, John. And thank you all for those reflections on what it means to be a true physician.

I think it's obviously a huge topic and a lot of the stuff you're saying seems to be contrary to, as we've been talking about, the popular understanding of the modern physician.

And certainly as a pre medical student, I didn't think of a lot of these areas that fell under the role of physician. And yeah, I don't think I had the sense of pursuing these ideals in the same way that you're talking about or truly being holistically formed rather than just becoming an expert in medicine.

So with this in mind, how did we come to the understanding of a physician that is so different from what a true physician is? How. How did modern medicine end up this way?

And where do we go from here?

I'm just smiling because Brew and I have taken a couple stabs at this, some of which have gone better and some of which have gone worse. But there's a very long story to be told about medicine in the Western tradition and how we arrived at this cultural moment and much of what ails.

I think contemporary medical training and practice can be described in that story, but it would be perhaps for another series of podcasts.

I think that.

I guess there's. There's two ways I'm thinking about answering this. One is like trying to recount a story of, like, how we potentially arrived here. And the other is like talking about what the sort of real world empiric data and anecdotal experience tell us about how people are struggling.

Well, I mean, I'm struggling too, to like.

The story's so complex.

I'll just start here. Here's how I've come to think about it. Burnout was named probably for the first time in 1973 and 1974. And we've now had, you know, 50 years to kind of think about this phenomenon.

We've had at least 20 to 30 years of thinking about healing medicine with health and humanities interventions and wellness initiatives in particular, over the last 10 years.

And I think what that has revealed to us as we've tried to figure out this problem and articulate it together is at least three things.

The first is that even asking this question is very hard because we clearly don't even know where the problem really lies.

It's common to blame it on Covid.

It's common to blame the burnout phenomenon on stuff like EMR and kind of increased financial throughput pressures. And all those things, I think are true.

It's common today to render the problem in terms of moral injury or moral stress.

I think it actually begins insidiously much,

much earlier. And I know Ben can talk about this better than I can about Francis Bacon and the Baconian Project,

which goes way back, but I think about technology,

bureaucracy, and this total work mentality that we've inherited, at least from the 70s and 80s, that just our very culture is such that at least in North America,

we consider our primary identity as that of worker.

And the way that you know this is true is because when people are working, often all they can think about and dream about is the rest they wish they were having.

And then when they're resting, all they can think about is the work that they feel guilty about not doing. That's Walter Buchanan's definition and Rest of God in which he makes the call to restoring Sabbath.

But basically this idea that comes from Peter Berger in the Homeless Mind,

Modernization and Consciousness, that modern work is defined by maximum production,

technocracies and the technocratic turn.

Everything's about efficiency and getting things produced as quickly as possible. And in medicine, that looks like seeing more and more patients in less and less time. It looks like current vertical integration trends in which hospitals gobble up all local forms of care to make more money,

to see more patients.

And then Berger also says that the bureaucratic turn is a constitutive state feature of modern work. And again, he wrote this in. In 73, the same. Same year burnout's being named.

And bureaucracy, he says, is defined by passivity,

by this kind of taxonomic impulse in which everything has to be named and described in such a way that actually kind of makes our roles ever more siloed.

Where you get to these really truncated definitions of professionalism, because they actually make sense. If your job is just to empty your epic in basket at the end of every day.

And what that produces, what Berger predicts will happen, will be an anxious, fragile life is the word he uses.

And I think that's on display in the burnout phenomenon for reasons I certainly. I want to be careful because I don't want to.

I also don't want to like,

dismiss or be cavalier about the deep sense of moral fatigue and betrayal that patients and physicians experience today.

So I'm rambling, but lots of ways we got here. The. The ones I'm trying to name are how total work mentality and how you can become someone who works to the point of burnout, resignation, or worse.

And then how the techno bureaucratic turn has changed how physicians understand themselves within the practice of medicine. That it's become more of a product,

less of a practice in which talk of virtues and ideals is less and less coherent because it doesn't increase the likelihood that you'll be productive worker.

Yeah,

thank you for reflecting on both of those top or this topic from both of you. And the thing that it brings to my mind is as a resident, that I felt a lot of these things as well.

This idea of wanting to be a good physician, but then getting lost in the sense of what we also talk about in the Hippocratic Society, this idea of the checklist mentality where we get really good at checking off boxes and it becomes about efficiency as the end goal rather than the ideals that drew us to medicine in the first place.

And I think that it comes back to this idea of what is a physician as well,

in the larger sense of this idea of the pursuit of the good. Because I know one of you mentions the idea of physician as provider, which is a very common term that we use today.

But if we conceptualize physician as provider, then in a certain sense the natural evolution would be that the end is perhaps efficiency or efficiently providing resources or goods or whatever that might be.

Just providing things in the end is what it means to be a good physician.

And so I think even the vocabulary that we use is important when we think about what it means to be a physician. And I think that that itself also is kind of an interesting reflection that you guys brought up.

Yeah, I mean, I was talking to one of our medical assistants who's applying to medical school right now.

What do you think the ideal physician is? And basically how did we get here then? Not exactly in those terms.

And it was fascinating kind of hearing him articulate basically something like provide whatever legally available products or services it is that the patient sincerely desires.

He didn't say it quite like that, but that's kind of what he was saying was like, yeah, just show up like you know,

use your training and help the patient get what they're looking for. And that's very different than like practicing presence and feeling the need to care for the suffering other in front of you.

It obviously is going to entail using your knowledge and training and competence to make wise decision about the patient's health. It might involve technology and so forth, but doesn't fully capture what's going on here.

So,

I mean, I think all that Burr said about specifically the last 50 years of both technocratic and neoliberal assumptions of work and how that bears upon medicine is spot on.

The broader historical context that feeds into those impulses.

I'll just draw on two separate works to kind of try to tell the story concisely. So Gerald McKenny is a believe, a theologian or ethicist. I think he's at Notre Dame, wrote a book that I believe is culturally the Human Condition,

where he puts forth this idea of what he terms the Baconian project, where he makes the argument that Francis Bacon is instrumental in the process of basically ushering in an empiricist and scientific worldview that understands the world that we inhabit primarily as something that can be quantified,

studied systematically, and ultimately controlled.

Bacon was a Christian, but he said, and he believed that the task of humankind,

which ultimately had important sort of resonance with the Reformation and Protestant thought,

was that we can harness our ingenuity and technology to understand the patterns of the world, to ultimately enact therapies to relieve the human condition, which is to put an end to suffering as we see and experience it.

Bacon's scientific and ethical goals and thoughts were bounded by a Christian faith.

So his project, the Baconian project,

was ultimately in subordination to service and worship of God. And the idea of harnessing technology and our ingenuity to relieve suffering was circumscribed by Christian commitments.

Importantly, Bacon is sort of the entryway into this impulse again towards a focus on scientific method, empiricism, technology and control,

with the goal of relieving suffering. As medicine is sort of established as a tradition,

and with the story of the west and the sort of increasing secularization,

the limits on that endeavor of relieving suffering are progressively liberalized because there's no qualifier, no sort of teleological theological end which might constrain it. And so McKinney's argument is that taken ushers in this way of viewing the world of thinking about sick and suffering patients which we now inherit as physicians today,

whose goal is primarily to relieve suffering by any means possible. Which has implications for all sorts of ethical issues, including physician assisted suicide, but also the firm belief in our ability to harness technology and sort of the techne that we talked earlier about,

which can lead to a certain sort of epistemic hubris.

The other part of this story is drawing on Jeff Bishop's work, the Anticipatory Corpse, where Bishop makes a really important argument that the animating metaphysics or sort of view of causation and the way that ultimate meaning is understood in medicine is one of what he would term efficient causation.

So because we live in a pluralistic society that can't agree on an end or tell us towards what we do,

medicine, again through a long story, including the work of Bacon,

has come to view its work as exclusively dealing with questions of proximal cause and effect.

In issuing ultimate questions of what the purpose of medicine is and the end towards which we strive as physicians, we can only sort of concern ourselves with what we can measure, what we can intervene upon.

And we have no ability to say what we should ultimately strive towards physicians or what patients should hope for,

because that's a decision that's sort of left to them.

So both of those forces interact in complex and powerful ways to, like Brewer was saying, I think,

ultimately complicate the ability of physicians to speak robustly about what the good is that they work towards.

And that sort of delimit the tools that we work with and the way that we understand what it is that we do in really sort of a disenchanted and primarily technical manner that's predicated on control rather than ultimate questions of good and flourishing for patients.

That's as concise as I can put it.

That was epic. It was awesome.

Well, thank you for that, guys. I'm very struck by the extent of the causation of the problem from Francis bacon to the 70s to Covid,

really goes much deeper than most people think, I imagine.

So now that we're here, where can we go from here? What can we do for ourselves in medical training,

for physicians who are already formed, if you might say, how can we form ourselves and our colleagues in this way? And how do we become the ideal physician?

Yeah, it's an important question. I'm glad that you asked it. And I feel at this point it's necessary to sort of say that. I recognize that much of what Brewer and I have said, and this is something that we struggle with in our writing and thinking together,

can be interpreted as hypercritical and in some ways maybe despairing of our cultural moment. In medicine.

And I want to try to begin the response to your question by saying nothing could be further from the truth.

I know that the sort of diagnosis that we've made read can sound dire,

but I think, and I've experienced medicine to be an incredible vocation that brings joy and fulfillment and flourishing in a way such that I couldn't imagine doing anything else.

And so, especially for the younger listeners out there, I just want to emphasize that I think critique is important in naming the forces at play.

But it's also true that this is really, really good work that we're incredibly privileged to do. And so I'll offer a few preliminary thoughts about kind of where to go, especially as a.

As a trainee or someone early in this process.

First, I think that it is absolutely crucial and instrumental that one embed oneself within a community or tradition that can grapple with these questions of purpose, meaning, of goodness, of suffering,

of tragedy,

because the sort of default language and frameworks within contemporary medical education don't really have room or space for that.

Brew and I are both Christians, and that's a primary way we see our work.

But there are other robust traditions, both religious and not explicitly religious, that offer important answers to this question.

So I think finding a community of folks,

even if they're co residents, co fellows, again,

to sort of ask these questions with, is absolutely central,

to think critically about what it means to pursue the good. Second,

I can't overstate the role,

the centrality of role models. This is again, a very Aristotelian notion that John was talking about ideals earlier. Right. And sort of virtues and excellence,

those are only ever instantiated in real people, in real places, in concrete situations. Right.

And so finding someone who practices medicine in an excellent way,

which can be both objective. Right. But also there can be a certain, like, ineffability to somebody who's just a really good doctor and actively seeking, amidst the sometimes fragmented processes, medical education and training, where you're rotating constantly to seek to get to know people who do the work really well,

and asking very direct questions from them and seeking to come alongside and learn from them as something like an apprentice,

I think is really important. When I was a resident, an intern, and saw great residents I worked with, I was not shy about saying, like, hey, you're really good at this, and these are the ways that you're good at this.

And I would really like to learn from you.

And you'd be surprised, maybe not surprised, but people really like hearing that and become really inclined to teach. And I think to show in a way that is not necessarily second nature.

So role models. And then third, and finally,

this relates to the discussion of finding sort of moral communities to embed oneself in,

but being able to be held accountable by someone or something outside of medicine.

I think family is crucial here. I'm not married and don't have children, but for those who do, I think spouses and children play a crucial role. It's also true that something like a church, a moral community that can lay claims on someone,

that supervenes the claims of medicine, supersedes the claims of medicine,

that says, I recognize you're a doctor, and everybody thinks that doctrine is the most important thing, and no one's ever going to ask you to do things, you know, that might impinge upon your role and responsibility as a doctor.

But having people who can hold you accountable, who won't let you make excuses, who recognize that there's a higher good that you're called to,

to help properly orient, you know, your identity as a physician, which is important,

but ultimately, I think must be oriented to some ultimate end or purpose.

And having the humility to submit to other authorities in the course of our life and relationships, I think is, Is necessary.

Yeah, I, I completely agree and exclamation point everything Ben just said. I,

Yeah, I mean, I, I don't have a lot to add. I, I would add the, the importance and possibility of, of small groups and forums just having the imagination to gather around other students and colleagues and residents who are thirsty and hungry for these very questions.

I think is a place we go from here. Whether it's starting up, literally a small group or having a more administrative role in a, in a program, residency program, or even your institution.

I mean, the Hippocratic Society is obviously example of this very thing.

And then second, I would say the letting the.

What William Carlos Williams might have called the frail genius of the place peek through our present obscurities. Meaning that when in doubt, it's been my experience as a young doctor that caring for patients clarifies who it is I am and who I'm becoming and what it is I am to do.

And again, I think that John didn't pay me to ping the Hippocratic Society so much.

But, you know, y' all's emphasis on cases and drawing on cases to introduce the virtues is deeply. Right. Right. Because it's, it's at the level of the bedside that these things are learned and clarified.

And then the, the maybe the last thing I'll offer is, well, two things. The,

the first being that alternative. Alternative forms of practice that show us a better way to live. It's easy for me to talk about this because I'm in a direct primary care context, which is not concierge.

It's a different form, but a way of trying to restore the moral clarity of at least the work of primary care between patient and doctor.

So just to say that part of recovering Professional Witness might look like institutions building new ways of practice that we don't yet know,

and being willing to engage those which obviously can, will take courage and sacrifice.

And then finally, I'll just. I'll talk about beauty.

This is part of my inheritance from my family, but also my early training as a. As an artist before choosing medicine. It's important to me, but. But I really do think that beautiful things can disrupt our assumptions about what it is we're doing.

They can.

Sure, they can delight us and awaken our longings,

but a truly beautiful thing calls you upward to something great in a way that can be both chastising and deepening and disorienting and yet reorienting all at the same time.

So insofar as the health, humanities and arts and medicine projects try to restore professionalism in medicine, it seems to me it must be the kinds of interactions with beautiful things that move our hearts and our minds upward towards ideals,

but in a way that's always rooted, in a way that's always in view of the. Of the suffering other and the wounds of.

And the wounds. Yeah.

Thanks so much for that, that summary. And it's true, obviously Ben and Brewer are here because they appreciate the work of the Hippocratic Society.

And also it's amazing how this comes together so well because of,

one could say, our preoccupation with what it means to be human.

Right.

That what we talked about today,

identity formation as a physician, also comes down to understanding ourselves more deeply of what it means to be human, ourselves through those bonds, those relationships, those communities that we form through humility, which is another topic that we've spoken about in the past of role models and having the humility to look up to and also receive kind of the gift of being formed by role models.

And then also that virtue that is so crucial, prudence of understanding us in the context of the work that we do. And how there is also more outside of the just medicine itself and that idea of being held accountable within a larger community.

Also speaking to this deep sense of identity,

of what it means to be just not only a human, but seeing ourselves as, as Professor Snead says, within the context of our relationality with others and that being deeply human.

Thank you guys so much.

Dr. Frush, Dr. Eberly, Dr. Rhee,

this has truly been extremely extraordinarily informative, but also just an incredibly beautiful discussion and I've learned so much and I hope our listeners have benefited as much as myself.

Thanks so much, Michael.

Yeah, thank you.

Thank you both.

Great. Be sure to check out the follow up episode to hear more about professionalism and physician identity. And we'll see you next time on the Hippocratic Society.

Thank you very much for joining and reflecting with us today.

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And as always, we'll see you next time on the Hippocratic Society Podcast.

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