I went to the ACEP Scientific Assembly in San Francisco this year. Although I was only there for two days, I learned a great deal. Our specialty is populated by intelligent, capable physicians, and I am always humbled to be in their company. I am endlessly impressed by their dedication to the health of their patients. They practice, they research, they probe the boundaries of mortality, always looking for new ways to slip people across the border between death and life. For that I thank them. My family has benefitted from the collective efforts of our specialty over the decades.
And yet, as I sat in that enormous lecture hall, as I listened and learned, as I looked at all the bright eyes and minds, I had to wonder, do physicians have a framework in which to view the implications of medicine, of suffering, of death and loss, of hope and joy? Do they understand what it is that compels them to reach out, day and night, to some of the sickest and most difficult patients, in some of the worst situations imaginable? Do they ask why medicine is necessary at all?
That is, physicians are great at what, when, how, and where. But are they as facile with why? I speak to many medical doctors, nurses, nurse practitioners, physicians assistants, and medics. My readers are so gracious; they write to me to share their lives and struggles and to tell me whether they agree (or disagree) with what I say. But in the end, I only hear from a small number of the many practitioners out there. How is everyone doing, not with the nuts and bolts, but with the larger questions of medicine?
Maybe that sounds kind of nutty. I mean, the majority of us came from science undergraduate degrees into the science of medicine. Admittedly, it's not all science, but what we do is researched and practiced in a scientific framework. It's the reason we have the evidence-based medicine paradigm. As scientific as we may be, however, questions still need to be asked and hopefully answered.
Even as we understand the pathophysiology of sepsis, we ask ourselves, deep inside, why this beautiful newborn child? And though we know the mortality of aortic injury, we ask, why this vibrant teen? When an aged woman holds the hand of her dying husband and tears streak her wrinkled face as if she were teen bride, we ask, what's next, where is he going, will she see him again? And when the young man is beaten to death over a drug deal, we ask, why would anyone do that? Why are people so ... bad?
Death, suffering, loss, and evil alongside hope, joy, love, and devotion — all of these are things we seldom hear about in our medical education. Of course, it's only four years of medical school plus whatever one's residency happens to involve. But they're important concepts. Important but controversial. Attempting to answer them requires a framework, which is often cultural or (horror of horrors) religious in origin.
Our educational establishment has become more and more materialistic over the years. Not as in “give me money” (though tuition costs might suggest otherwise). What I mean is that we offer only material, temporal answers to the enormity of the questions and issues that swirl around physicians. The physical problems we see are manifestations of the philosophical, ethical, theological, and spiritual tsunamis that crash over us every single day of our practices.
Indeed, I suspect schools have replaced formal discussions of these issues with a new kind of religion: one that worships tolerance, acceptance, multiculturalism. This just gives us excuses to avoid the harder, higher questions. You know, the ones our patients look to us with, their eyes pleading for some kind of answer from what they perceive to be the smartest person in the room? The person trying to comfort them who has as few answers as they do.
Tolerance, acceptance, and multiculturalism once allowed us but now force us to avoid substantive answers to anything for fear of the worst of all modern afflictions: offense. Rather than say, “I'm sorry for your suffering, but here is what the Buddha said; maybe it helps.” Rather than say, “I know that it hurts, but Jesus suffered for us, and here's what He said.” Rather than say, “Allah is just; believe in justice.” Rather than say, “I believe you will meet again in another life.” We say, “Well, you can't explain these things, you know?” We pat their hands, and say, “I'm sorry for your loss.” And let's face it, some of those suffering don't have loving families or enormous intellectual resources. They take our token comfort, thank us, and go get high, get drunk, or exact revenge.
Tolerance and all its implications had noble intent in the American tradition, to avoid oppressing others with the power of our own beliefs. This has left us with generations of people unwilling to commit to any idea and even less willing to convey it to others, even if it offers comfort or hope.
We all believe something. We practice from different perspectives, atheist or theist, Christian or Hindu, and everything in between. We must reject the fear of offense, and do our best to offer more than material hope, more than casual comfort, and more than cursory answers to the great questions. And it is even more critical that we search, ask, read, and think. That we develop our own philosophy or theology, our own way of putting the pieces together that makes sense, and is (as far as we can see) consistent with the evidence of our lives and the lives of those entrusted to us.
We need answers and ideas in our pharmacopeia even more than we need the latest drugs and procedures. We need answers for ourselves as we drive home contemplating the tears of the grieving, as we imagine the beautiful faces of our spouses and children. We need them because big questions and great struggles will always remain in this life. For the foreseable future, death will continue. And we even need to ask about that rock wall we chip away at every day: Why death at all?
Until we're willing to look and attempt to offer answers, we may remain little more than talented technicians and mechanics for human bodies that struggle for a few decades for no discernable reason that we can identify.
How much better to attempt to exlain it! Even if we find we're wrong in the end, our word will have been more comfort than we can imagine. Isaiah, said it so simply, and Handel gave it to us so beautifully: Comfort ye, my people. Without a framework of why, then comforting words can ring all too hollow.
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