4.2 - Integrity

[Intro music]

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.

Unknown

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

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Michael Egan

Hi, and welcome back. My name is Michael and I'm joined again by Dr. John Rhee.

Michael Egan

Today's episode follows on our interview with Dr. Brewer Eberly and Dr. Ben Frush,

Michael Egan

talking about physician formation and identity.

Michael Egan

As we bring these concepts into the practical aspects of the job, we'd like to take a look at integrity,

Michael Egan

which helps us develop and hold fast our values and ideals.

Michael Egan

And so, as we're starting to talk about this virtue of integrity, I thought we could start out with a story.

Michael Egan

Kelly had just started her peds rotation and was already loving it.

Michael Egan

She had wanted to go into PEDs since entering medical school and knew how important this rotation was for when she was applying to residency.

Michael Egan

She was also rounding with Dr. Haley, the head of the residency program at that hospital,

Michael Egan

which would be far and away her top choice.

Michael Egan

She had been asked to take Kyle's history and physical,

Michael Egan

something she had felt like she had already done a million times, but mostly on adults.

Michael Egan

When reporting back to Dr. Haley, she was asked whether the patient had any right upper quadrant abdominal pain, and her mind blanked.

Michael Egan

She remembered him saying his belly hurt and knew she had asked about specific parts, but somehow didn't write down his answer.

Michael Egan

She had already made two mistakes today and didn't want to give a bad impression.

Michael Egan

And she thought she remembered him wincing as she palpated that region.

Michael Egan

Yes,

Michael Egan

she said to Dr. Haley, and Dr. Haley ordered an abdominal ultrasound and thanked her for the history.

Michael Egan

So, using this example as a starting point,

Michael Egan

what are we talking about when we say integrity? What does that virtue really mean?

John Rhee

Yeah, I think this is a great case, Michael, because it touches on an experience that all people who went through medicine or medical training experience. Right.

John Rhee

This balance between wanting to perform well and also telling the truth. Right. Being a person of integrity.

Michael Egan

Right.

John Rhee

And so the integrity, or integrity is this idea that Pellegrino would describe as a person's commitment to live a moral life.

John Rhee

And in this case of Kelly,

John Rhee

I think the important part to perhaps tease out is this idea of, like, what is the ultimate good that she was trying to pursue here?

John Rhee

And was it the good of the patient? Was or was it some Good based on herself, right? The sense in which the end was just about performing well, even if it meant that perhaps an unnecessary test was being ordered, right?

John Rhee

And so the integrity of a person is this idea of a right ordering of the parts in relation to the whole,

John Rhee

this idea of balance and harmony between the different dimensions of a person's existence that's necessary for the healthy functioning of the whole.

John Rhee

And so when we think about the idea of integrity, or even just a word, we think about it as this part, this concept of an integrated whole, right? Where there's nothing missing.

John Rhee

In fact,

John Rhee

Aquinas talks about this idea of integrity in the context of one of the three primary characteristics of a beautiful thing, along with proportionality and radiance.

John Rhee

And so integrity, proportionality and radiance are considered critical in the architecture for, let's say, a church.

John Rhee

And so this also highlights another aspect of integrity which shows that a person who lives integrity seems to also reflect something that is beautiful.

John Rhee

So it implies a value system to which we are holding on to that is in accordance with the good. And it's acting not just according to the values you hold because you hold them, but rather also because you have reflected on the fact that it is towards a good end,

John Rhee

right?

John Rhee

And,

John Rhee

you know, in the case of our patients, illness causes this disintegration of parts, right? This falling apart of integrity of the person as the body became. Becomes a main concern and no longer a means for potentially living the life that the person had hoped to be, right?

John Rhee

And so the core values of a person that contribute to their identity are oftentimes impeded by illness.

John Rhee

And therefore, this is where the role of the physician comes in, where the physician, therefore,

John Rhee

through the relationship with the patient,

John Rhee

tries to restore the patient to health and normal functioning of the body in order to try to restore this integrity of the person.

John Rhee

I think just a last thought about integrity, which we alluded to in the beginning because of this aspect in which Kelly was not telling the truth,

John Rhee

but is that there are two very strongly adjacent virtues to it, which is honesty or truthfulness, right? This aspect of integrity, where we have to tell the truth in order to be a person of integrity,

John Rhee

and then sincerity as well, where a person is not just truthful to others, but is also truthful to oneself and one's own intentions and reasons for why they are doing certain things.

Michael Egan

So it seems like you're breaking down integrity into two categories, both dealing with values, the first one in ourselves and how we develop our own values and hold fast to those.

Michael Egan

And then the second Being in our patients, how we can help them follow their values in a happy and flourishing life.

John Rhee

Yeah, that's right.

John Rhee

I think that there is a theme that we talk about in the Hippocratic Society where the virtues that we're talking about are not isolated. Right. So we're talking about them in the context of medicine, because to be a good physician,

John Rhee

one has to grow in the virtues.

John Rhee

And therefore, even this example of Kelly, we can see how the growth in integrity directly impacts the good of the patient or their health. Right.

John Rhee

But unless one is living integrity well in one's own life outside the hospital,

John Rhee

it's really hard to say that there's some artificial divide between walking through the front doors of the hospital and walking out of it back into one's own life. Right.

John Rhee

There is a sense of continuity, and that's especially the case with the virtues,

John Rhee

where how one lives one's life in the small details affects one's life in one's professional life when making decisions, including about the care of other people's lives.

Michael Egan

Great. So I think that's the perfect transition to dive deep into specifically why integrity is so important for a physician.

Michael Egan

You were saying that all the virtues and your entire life outside the hospital affects inside the hospital.

Michael Egan

But why integrity specifically for the physician?

John Rhee

Yeah.

John Rhee

One of the things that. One of the main points that I just want to get across is that integrity is necessary for real trust. Right. And so we have this experience in our own lives through friendships where the friend who never lies, so the friend who,

John Rhee

you know, says things as they are to us,

John Rhee

is truthful in no matter what circumstance, even if they know that it could be a detriment to themselves,

John Rhee

That's a person that we come to trust not just in small things, but also in big things.

John Rhee

Being the godparents to our children, or even confiding in them in really heartbreaking things,

John Rhee

or depending on them in times of deep suffering. Right.

John Rhee

And so for a patient to also be able to develop that physician patient bond with us,

John Rhee

integrity is crucial because a person who lives integrity well then is able to be a person who the patient can trust no matter what.

Michael Egan

Right.

John Rhee

So I think that that's, like, one major aspect of it.

John Rhee

Another aspect of it is that there's, again, in this definition of integrity,

John Rhee

this wholeness. Right. That it is a unification or coming together of all the pieces in which it falls together into this unified whole.

John Rhee

And so if we live a life without integrity,

John Rhee

where there is a part in which we are hiding or a part in which we are not being Truthful,

John Rhee

then we cannot actually fully be ourselves.

John Rhee

Not only from a practical standpoint, where,

John Rhee

because we might have to be constantly covering up some lie, perhaps that we told and that exerts a lot of cognitive pressure or energy,

John Rhee

but also when we start to disintegrate these aspects within ourselves,

John Rhee

then we come to not know who we are,

John Rhee

what we believe in,

John Rhee

and therefore we do not know like what the ultimate good is in which we are pursuing.

John Rhee

And so we cannot come to have a set of consistent values in which we are trying to live our lives. And, and if that's the case, then we come to live our lives where our circumstances dictate the reasons why we're doing certain things.

John Rhee

We could see how that that would be terrible in our own personal lives, but also especially in patient care,

John Rhee

where we then may be dictated by the circumstances that are more stressful in order to do that which is more convenient.

John Rhee

If we don't have that backbone of the values in which we are trying to live a moral life, then it's very easy for us to disintegrate into pieces and having each of those pieces individually live out only one aspect of who we are.

John Rhee

Then lastly,

John Rhee

one important aspect I think, well, there are many reasons for living integrity well, but related specifically to the hospital is the sense in which integrity is also related to another adjacent virtue.

John Rhee

So we talked about honesty, truthfulness, and also sincerity,

John Rhee

but is related to another adjacent virtue, I think, which is the virtue of courage, fortitude.

John Rhee

There are times in medicine where patients well being, their health may be at stake because of a bad decision or something that was missed,

John Rhee

and where we don't have or perhaps even a moral issue, right? Where we think that something is being done to a patient that is not that which is morally right,

John Rhee

then it helps us to avoid this not my problem attitude.

John Rhee

It gives us a sense of responsibility because when we are used to confronting integrity,

John Rhee

which often relies us to be truthful, even in times that are challenging,

John Rhee

it helps us to develop the sense in which we can more consistently pursue the good of the person or the patient in front of us and have that personal responsibility to do so.

John Rhee

There's a great Lisa Rosenbaum article in the New England Journal called Not my problem, of this idea that we see a lot in medicine where there's a lot of passing of the buck, right?

John Rhee

Where there are so many subspecialists and therefore people are kind of like deferring the responsibility of a particularly challenging decision for a patient,

John Rhee

which may lead the patient to choose, for example, hospice or some Type of, just maybe months of some type of treatment. Right. And Lisa Rosenbaum talks about this particular physician who ended up just kind of rising above all that and then taking on responsibility and therefore moving forward a patient's care.

John Rhee

And I think that that represents integrity really well, where that person saw the.

John Rhee

What is good for the patient,

John Rhee

the sense in which somebody had to take that responsibility on, even though it's hard to do,

John Rhee

and decided to do it for the good of the patient.

Michael Egan

Thank you, John. That was very helpful. And it's very clear to see just how bad things could end up without physicians who have integrity.

Michael Egan

And in a sense, it seems that's really the core of the job.

Michael Egan

As you were saying, integrity depends a lot on physicians who are facing some sort of hardship, maybe in clinical practice, whether that's some sort of pressure or financial incentive.

Michael Egan

It seems that it's really the core of medicine where physicians are taking on the suffering of a patient and facing a disease that they are facing, which is hard for them.

Michael Egan

And so having this integrity where they're both able to face hard things in their own life and face hard things for the patients,

Michael Egan

it seems that that really is the core of the profession.

John Rhee

Yeah. And I think that one additional part that you brought up, this idea of perhaps other pressures. So we talked about pressures that may be internal, but there are also external pressures.

John Rhee

Right. Including financial pressures.

John Rhee

And so how we as physicians in this very complicated healthcare system live integrity out, where we make sure that our own interests are not coming on top of the patient's interest.

John Rhee

Right. That the patient's interest comes first,

John Rhee

and one who lives integrity can clearly see that which is the right end, which is always the good of the patient.

Michael Egan

Yeah, that's an excellent point.

Michael Egan

And so as we're talking about how important it is to practice this,

Michael Egan

why don't we move on to how can we practice this? How do we develop this virtue?

John Rhee

In a certain sense, integrity is a. As you could imagine,

John Rhee

all the things that we were talking about must start with the small decisions in one's life.

John Rhee

And in a certain sense, it's a virtue that one is growing with. But I would also say that it's in a certain sense,

John Rhee

an integrated whole of many of the adjacent virtues. And so one thing that I would say is that we could look a little bit at the adjacent virtues, which could perhaps have more practical implications in order to then be a more integrated whole or person of integrity.

Michael Egan

Right.

John Rhee

So let's start with the idea of honesty or truthfulness. Right. And so we could live well Honesty and truthfulness. If we are truthful in all circumstances,

John Rhee

right now in medicine,

John Rhee

there's like a lot of competing,

John Rhee

competing things, right? In our, in our daily lives,

John Rhee

including how we want to, how we are trying to perform and ranging to perhaps even complex things of, like, you know, I also have to show my patient that I'm competent, right?

John Rhee

And so despite the fact that we are talking about all of these complex things, I would still say that being honest and truthful is the most important.

John Rhee

And so we want to make sure that because it acts on the bond with the physician patient relationship. And so we want to be truthful in all circumstances. And so whether it's as simple as saying that the dinner that you cooked actually was not cooked and it was bought from the restaurant,

John Rhee

when people are complimenting you all the way to the example of Kelly, where it may actually affect patient care, where what she said in terms of being truthful affected a certain order that was then initiated, right?

John Rhee

So this idea of being truthful always.

John Rhee

Another adjacent virtue that we talked about is sincerity. And so sincerity requires an introspection. So I would say mindfulness here is an important aspect. Practice mindfulness,

John Rhee

because only when we have this practice of mindfulness where we are able to sift through all the emotional aspects that are in our life and be able to have a bird's eye view of not being just driven by different anxieties or stressors,

John Rhee

but able to see through that the good that we are trying to pursue and then using the intellect and will to then pursue that good that comes with the practice of mindfulness.

John Rhee

And mindfulness has to be practiced daily and in a way in which it's very, I would say, standardized.

John Rhee

And so when one practices mindfulness and within the context of mindfulness,

John Rhee

reflects on those values, those ideals that are most important to oneself,

John Rhee

then one is able to tease apart and be truthful also to oneself, right? And be sincere with oneself.

John Rhee

So there is an aspect of sincerity in which one is being honest and truthful to others. But in order to be an integrated whole for oneself, one also has to be truthful to oneself to maintain that integrity.

John Rhee

And then lastly, I think that aspect that we talked about the courage or afforded to that one needs in medicine,

John Rhee

the courage to be able to stand up for those things that we know are important,

John Rhee

especially as it has to do with care for the vulnerable and the weak and the suffering. Suffering,

John Rhee

basically our patient population, right? And so when we are also able to have the courage to speak out, say things in our, in our own personal lives,

John Rhee

then we're able to do that also for patients and therefore live integrity. Well,

John Rhee

I just want to end by saying that, as always, all of these virtues are governed by practical wisdom, by prudence.

John Rhee

And so how one lives that courage, how one lives the honesty,

John Rhee

how one lives the sincerity,

John Rhee

is directed by the prudential judgment that one gains over time and is important to develop prudence within the context of community,

John Rhee

because we don't always have the exact answer of how to live out certain virtues.

John Rhee

And there's a lot to be said about experience and wisdom of how to enact those virtues in different circumstances.

Michael Egan

Thank you, John. That's very helpful.

Michael Egan

And it's clear to see, going back to the story, how Kelly could have lived out integrity in a better way. As you were saying, being honest with herself, maybe she didn't really ask the patient where his pain was.

Michael Egan

And then being honest with the doctor and even having the courage to be on to be honest with the doctor and not let that fear or anxiety dictate all that she was doing.

Michael Egan

And so even mindfulness comes in there.

Michael Egan

So thank you very much. I hope that our listeners now can see how to practice integrity, both in their daily life and in their work at the hospital.

Michael Egan

And we'll see you next time on the Hippocratic Society.

John Rhee

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

John Rhee

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John Rhee

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