The Root of Moral Distress for Physicians
How Did We Get Here?
Medicine, for me, has always been a perfect amalgam of being present to the numinous while simultaneously dealing with things that are wet and stinky, bloody and torn, with shit and piss and pus and vomit and sweat. Being a doctor has meant standing at the cusp of the spiritual, being often in awe and wonder that coincide with and even arise from the quintessential grounding in the physical realm of touch, action, and tangible solutions. It is messy, immediate, and transcendent.
My mother in the ICU in 2010. She died two years later after recovering from another major respiratory illness that also required ICU care and a tracheostomy.
Growing up, I was a sympathetic puker, and I worried about this as I started medical school. If my little brother or another kid in grade school puked, I would, too. I’d be hurtling to a toilet or trashcan at their first retch. I wasn’t squeamish about a lot of other things, although when I was five and had my first loose tooth, I saw a giant tongue lying on a cutting board in my grandmother’s kitchen and put 2 and 2 together: the tongue sandwiches my family ate were truly tongue, thick slices of boiled cow tongue. That was the end of that for me. Blood sausage, too. At the start of residency, after years of being vegetarian, I began to eat meat again as a practical concern. I knew I would be short on time and money and using meal tickets to eat in the hospital cafeteria. Being more flexible about my diet was a perhaps ill-founded survival strategy. Even so, the increased time I spent in the operating room smelling burnt flesh and organs from electrocautery made me draw a line at barbecues. It became clear that only cultural prohibition separates food meat and human tissue.
I did not grow up with any kind of formal religious practice or faith but rather with strong principles about justice and equality that defined a moral society and a life worth living and well lived. As I came into young adulthood, already a decade into imagining my future as a doctor, I found feminist theology that articulated an embodied spirituality and the damaging consequences of splitting off the spirit from the body. I intuitively gravitated towards this; after all, we come into this life in a physical form, and it is through that form that we express the life force and manifest an individual expression of a greater whole. Medicine held allure as a path for living into this idea every day. While other physicians might not express it just this way, I believe this sensibility underlies what is compelling about this path for many physicians and why medical dramas are so intriguing and successful. The arena of medicine brings us into the thin places between the sacred and profane. We discover, enact, and reinforce fundamental dimensions of humanity.
In my personal formulation, the sacred, numinous aspect of medicine comprises the third of a triad of priorities. Ideally, it should stand in right balance with the other two—prosperity and applied knowledge, but it does not. Disillusionment, maladaptive strategies that are deemed practical solutions for managing the challenges of doctoring, and over-valuing rationality (or at least an overly simplistic understanding of rationality) lead too many doctors to disavow this vital, animating aspect of medicine. The disavowal, which is importantly a disavowal of self, is the charnel ground for the relational aspect of medicine and professional ethics. It forms the beginning of moral compromise that physicians make, often in the name of “getting real” or “growing up,” that too frequently gradually transforms the work of doctoring into a kind of personal hell.
Let me state even more clearly that moral distress doesn’t just happen to us. It isn’t imposed on us from the outside. Rather, it takes up residence in the place where we have already compromised ourselves, already violated our inner code, and then it swells there, forcibly widening the gap between what we believe and what we’re willing to do. When we turn against our own dream and calling, when we regard our sensitivity to the numinous in medical encounters as sappy or immature or anti-scientific, we do ourselves actual harm and pave the way for the exploitation of what is good in ourselves and the cultural institution and traditions that are Medicine and the archetype of healer.
The phenomenon of “healthcare,” a term that is an entirely commercial invention of transactional, extractive, industrial healthcare designed to dismantle and co-opt the sacred dimension and symbolic power of medicine, is not Medicine. Every doctor, nurse, and other person called to the healing arts should stop using that term to describe what we do. Healthcare appropriates the numinous, third priority of Medicine as an asset and exploits it to extract as much wealth from society as possible. Corporate healthcare must pay sufficient lip service to this aspect of medicine to retain its customer base, but it has absolutely no concept of why it is important or what it achieves beyond its value as a marketing tool. When corporate healthcare successfully exploits this quality, it opens to plunder the limitlessly deep pockets of people who care about life and relationships. This is why I think it is critical that the people who feel into the idea of what is sacred in Medicine—and I hope I have made it clear this is not about organized religion, per se—avoid using industrial terminology to describe our work. “Healthcare” is not what called us. We are not “healthcare providers.” We are doctors, nurses, physical therapists, counsellors, psychologists, occupational therapists, phlebotomists, body workers, art and music therapists, speech therapists, and more, each interpreting and giving expression to the healer archetype.
In Salena Godden’s beautiful and darkly brilliant novel, Mrs. Death Misses Death, death is envisaged not as the grim reaper but as an elderly black woman who is a housekeeper in hospitals, so unassuming, so invisibly yet ubiquitously present. The power of forces such as repair, interconnectivity, and the cycle of death and renewal are likewise, in the same breath, ordinary and profound precisely because they are constitutive of the experience of every person, the individual who is both a distillation of and a co-creator of the whole. All of us who gravitate to the space of healing, birth, and death, understand on a visceral level what being in the presence of the profound feels like; we recognise being enriched by something beyond the holy dollar, something far more potent. In a poignantly crafted story of recovery from a traumatic brain injury included in her book Wisdom of the Psyche: Depth Psychology after Neuroscience, analytic psychologist Ginette Paris recalls as freshly as if it had just happened yesterday the healing power of being taken into the arms of a nurse’s aide during her ICU stay. This woman simply held Ginette and hummed to her as she changed the soiled bedding. Paris writes, “I am saddened at the thought that the medical establishment does not seem to understand the power of those rare and precious individuals whose hands, voices, smiles, bodies, eyes, smell and heart, have the power to give a transfusion of life from heart to heart.”* She is describing healing presence, and already, more than two decades ago, she found the nurses were often perfunctory, severe, and too busy to attend to her in just this personal, loving way.
When the electronic medical record was just being implemented for inpatient care, a well-meaning nurse asked me if she could give one of my patients a cool compress for his forehead, which he requested to help relieve a headache. “Of course,” I replied, wondering why she asked. Then she asked me to write an order for the compress, and I couldn’t understand why. Was this a prelude to writing orders for other ordinary nursing interventions, like holding a patient’s hand? Would even this sanctioned touch soon require a prescription? The nurse educator for the ward explained there had recently been focus on the hazards of applying cold and heat to patients (k-pads, ice packs, warm blankets and so forth), but she also readily understood my concern that an order would have to specify temperature, duration, interval, and indication—each of which would require nurse documentation. It illustrates the Foucaultian nightmare of the self-perpetuating nature of power and of surveillance as a form and exercise of power (see his discussion of the Panopticon in Discipline and Punish: The Birth of the Prison).
It was only in my last year in academic practice after being subjected to an ambush and shocking rupture with my section chief that I gave myself permission to do and say things in the operating room that had been burning in me for more than 20 years. Enraged by wanting to replace me with a more malleable, younger surgeon and finding that our chairman was unwilling to endorse firing me, he resorted to threat: shouting, shaking, and red, he asserted he would “fucking destroy” me if I refused to submit a nonrewal-of-contract letter. I started receiving my patients in the operating room where music they selected was playing and a warm flannel blanket was on the operating table to envelop them as they transferred from the gurney. We lowered the lighting a bit and quieted the room as the anaesthesiologist worked. I encouraged the anaesthesiologist to dab an essential oil suitable for adults, such as lavender or lemon, on the face mask as they used fruit or bubblegum scents for children. Studies had shown that talking to patients during surgery improves pain scores and reduces postoperative analgesic requirements. As our patient went to sleep, I stood alongside her/him/them and whispered close to the patient’s ear the words Dr. Gordon, a surgeon teacher in my medical school preclinical years, said as his patients were going under anesthesia and upon their emergence: “I’m right here with you, Sam, and I’ll be here until the cows come home,” and upon emergence, “Your operation is over, Sam, and the healing process has already begun.” I strove to maintain calm authority in the operating room as the patient went under not because, as attending surgeon, I was captain of the ship or “deserved” respect but because every patient needs to feel confident that the attending surgeon has their care in hand and a seamlessly cooperating team so he/she/they can relax as much as possible and trust the process. More than once, a colleague working from an entirely different (and often depressed or stressed) mindset misunderstood me. This isn’t about ego; it’s about being a conduit for a process that supersedes any of us individually but in which we each have a role to play. This is why the attending surgeon needs to be present—present physically, psychically, and metaphysically—before anaesthesia is induced, not just for time-out procedural reasons, but to carry this greater significance for the patient and the team who are taking a remarkable journey together that may be familiar to us but is never, ever routine. It is also what protects our integrity. The reciprocal benefit for us is helping us remain intact as human beings, humble, and in correct proportion.
I’m sure it made me seem strange, at the lunatic fringe, but it was right, and given how broken down the system is that could allow and retain someone so base as my supervisor over someone so grounded and resistant to corruption as I am, I stopped caring so much about pleasing or catering to the dysfunctional. I got more real, more true. This is a form of resistance, and while it is threatening to doctors who will do almost anything to protect their salaries, it is available to every doctor, every day. I call this “micro change,” and it is extremely powerful. My supervisor’s reaction is a measure of this.
A couple of weeks ago, I had a conversation with a remarkable premedical student I worked with when he was a research assistant during my recent three-year term as the executive director of a small surgical research foundation. His parents are immigrants from India who built a life in the US and a solid foundation for him and his sister. He worked his way through college, paying for everything himself while getting top grades, doing research and community service in preparation for applying to medical school, and earning his degree in three years instead of four. He is of slight build (or creates that impression) and is soft-spoken, but he can bench-press 500 pounds, something I only learned about him when I read his medical school application essay. In the essay, he wrote about the conditioning that was more mental than physical, that called on a kind of solid belief in himself. He often describes himself as slower than his classmates, having to work harder and longer to achieve the same results they do. I challenge him about this because I doubt any of them paid their way through college or completed their degrees as quickly as he did. He has been determined, methodical, and realistic in his premedical studies and work.
Then he said something that made me reconsider something I’ve taken for granted during my last ten years exploring how to make Medicine better and the work of doctoring more sustainable and joyous. He, like many children of immigrants, was raised to value and felt duty-bound to honour the sacrifices of his parents (and you can substitute ancestors here) by choosing among only three professional futures: medicine, law, or engineering. He chose medicine. He has the character to become a fine doctor, even an exemplary doctor, but it made me revisit my notion that all doctors feel a sacred calling, even if that becomes extinguished or goes underground at some point. I began to wonder how many people do all the hard work of training and practice without knowing the hope and power, the wind in their sails, of the sacred intention.
What happens when medicine isn’t a calling or vocation but rather a job, a highly respected and skilled job but nonetheless a job? I can’t imagine sustaining this work from that framework, or at least I can’t imagine how one finds the reserves to be fully present to patients and each other without the energizing aspect of calling. The demands of being a doctor, it seems to me, are just too hard, too messy, too uncertain, and too burdensome to take on without the foundation of the soul’s call. I can see how this might take some of the sting out of working in the industrial healthcare model—there were no larger expectations that could be disappointed. It begins, perhaps, also to explain why so many physicians seem to be looking for “side gigs” and speaks to my puzzlement about what could possibly be as compelling as the work of doctoring and how they have energy to spare making their side gig succeed.
Fulfilling familial expectations still seems like too little fuel for this work. I suppose there is something larger, something purposeful about fulfilling the destiny of a lineage, that this could be an expression of dharma. It could prevent over-identifying with a physician identity and suffering each professional failure as a personal failure. It could pull us back from the “edge states” that medical anthropologist and Roshi Joan Halifax believes are the source of compassion overload, her framework for understanding and healing burnout (see her book Standing at the Edge: Finding Freedom Where Fear and Courage Meet). Still, I expect there must come a reckoning with self at some point when the identity and authenticity of the individual, apart from familial expectations, rebels and must be heard.
If you are someone who came to a career in medicine out of a sense of duty or obligation rather than fascination and inspiration, I would love to learn more about how that has or hasn’t worked. Has your motivation changed at some point through a discovery of the deeper structures of what medicine can offer? Is your motivation stable but sufficient? Is your experience similar to the best experiences some describe in arranged marriages where love grows through commitment and practice? Or has it been a long slog that demands the ongoing sublimation of your true desire? Are there questions I don’t even know how to ask because my personal framework is so different it’s hard for me to imagine? I am thinking of recording a series of very short, 10-15 minute conversations with doctors about their doctor genesis stories—what called you to this work—to share on the Metamorphosis Medicine website. Would you be interested in telling me your story? Email me (laurenkosinskimd@metamorphosismedicine.com), and we’ll set up a time.