Five Facets of the Excellent Physician

Earlier this month, I spent the weekend at the 1613 conference in Cincinnati. It was a collection of about 7,000 men from all over the country assembled under the banner of First Corinthians 16:13: "Be strong, stand firm in your faith, act like men."

The conference organized a series of incredible guys to speak, and, to be honest, there were several guys on the speaker lineup that drew me to this conference. One of these individuals that I specifically wanted to hear and engage with was former Green Beret and Virginia state delegate, now commentator and advocate for family and culture, Nick Freitas. (Sorry, John Lovell. I wanted to hear you too.)

During the conference, I had the incredible opportunity of meeting him personally, shaking his hand, and having a brief conversation. I told him that there are several people that I look to — that I attempt to pattern various facets of my life after for various reasons — and that he was among them. I have specifically appreciated his approach to faith, family, and public policy.

In the spirit of the conference, speaking specifically to men, Nick described five fundamental facets of our existence and how we should be engaging meaningfully with these as men. I found this framework helpful. And as we think here about medicine and physician life (especially living excellently in and through medicine), it is helpful to view ourselves as physicians in these five categories.

Spiritual

This is the fundamental and foundational piece of our life. But, it is often the area that gets pushed to the side, especially in a healthcare environment that emphasizes the secularism in science and continuously rejects or marginalizes religious and spiritual things. Nick explained how the spiritual aspect — our understanding of God, and in particular, the person and work of Jesus — is the most foundational aspect and is the sine-qua-non of everything else. If we don't have a proper understanding in this sphere, everything else will not function properly.

As I have attempted in this forum to promote excellence, define excellence, and call us as physicians to a higher standard, my initial attempts were to try to do this in a capacity that would be well received broadly by physicians — by all physicians — which means I downplayed specific spiritual language in my posts. But what I found is that when I tried not to use spiritual language — I kept coming back to it, because that was the fundamental basis for everything I was writing, and to not do that was simple moralism - in my own opinion. So, for us physicians, if we want to seek excellence, if we want to engage in work that is meaningful, if we want to serve our patients to the highest of our abilities, we have to first and foremost answer the big questions: Who am I? What's wrong with the world? How can what's wrong be made right? Those are spiritual questions. And this can only be done by looking to Jesus.

Emotional

The second is our emotions. We are inherently emotive creatures. We have feelings that are separate from our reason. Emotions are one of our distinctives as human beings and one of the ways we reflect the imago dei. We even have ways of targeting and identifying the portion of the brain responsible for our emotional responses - think amygdala.

As we engage with patients in our clinical practices, our emotions can be, at the same time, our superpower and our nemesis. There is much hype around the idea of AI and what disruptions this new and emerging technology will cause. I have been watching with great fascination as Tesla is working hard to refine the neural network that it runs in its self-driving vehicles. Drivers have logged 10 billion miles, so statistically the Tesla neural net is more experienced with road conditions than a human will ever be. I have been thinking that the same is likely going to be true in medicine. There will come a point when a medically trained AI will be more knowledgeable, more accurate, and more efficient than the top physicians at the top institutions. But what this model lacks is the human connection - the emotions of medicine. It lacks the ability to look a patient in the eye and empathize with the person on the other side of the stethoscope.

But where emotions are necessary in creating that human connection, it is equally important to keep emotions under control - to not allow them to cloud our reasoning or our interpersonal interactions. I was thinking back over a recent night shift and reflecting on the breadth of emotional capacity and responsiveness that is necessary to be an emergency physician. In one shift I found myself needing to calm a charged room of a crashing patient, respond patiently with a crazed, psychotic patient, and deal with an agitated and unreasonable patient. Okay, the last one wasn't my most shining moment, but it was entertaining for the rest of the staff. In each situation, the patients need us to find that right balance, to navigate the dichotomy of our emotional responses. Our patients need us to be emotional. But they also need us to control our emotions.

Intellectual

The third area of our existence as physicians is the intellectual. This is perhaps one of the most self-evident of the areas as we think about medicine. There is much that, as physicians, we need to know. We invest over a decade in the art of knowing things - understanding the background, the anatomy, how that anatomy works together, what can go wrong, how to fix it, risk stratifying disease, and integrating all of that together so that we can understand all of the unique scenarios that we will encounter, and can think flexibly - making inferences and connections. Medicine is a highly intellectual endeavor.

But in this realm of the intellectual, what is of greater importance than knowing is having wisdom. Some say that wisdom is knowledge coupled with experience. Proverbs defines wisdom as the fear of the Lord. The dictionary uses the term "good judgment." As we look across the landscape of healthcare, it is not hard to see the need for wisdom. Science has given us a great power to manipulate the human body. But at times we need to take a step back and ask the question of whether we ought to do something - whether there is some reason that we should constrain our ability.

When I was in medical school, we had a bioethics class. Perhaps the term "class" is an overstatement. It was a series of sessions with rudimentary instruction and facilitated group discussions where we engaged with challenging scenarios. In one such scenario we discussed whether we as physicians should oblige a patient who is suffering from a mental disorder that caused him to be distressed by the presence of his legs with an elective amputation of his legs. Far-fetched? I am now convinced that this was a precursor discussion to set the stage for normalizing the idea that we can chemically transform a man into a "woman" upon request and call it good. Knowledge tells us how this can be done and can even formulate a series of justifications. But wisdom asks whether we ought to employ this capability. It asks whether God intended our identities to be fixed and rooted in the embodiment that He gave us. It recognizes that there is much we don't know and can't know through science. As we engage with others, wisdom is critical.

Physical

The fourth area of our existence is the physical. Our patients are physical creatures. Our work is to understand the individual in the physical realm and use that knowledge to provide recommendations, make adjustments, or provide interventions to help the patient maximize the quality and quantity of life. Through our study and experience, we come to learn a great deal about the workings of physical biological life. Early in medical school, one of my instructors was addressing the class on our course of study. He told us that whatever we were studying, we could always peel back to a deeper layer. This has stuck with me throughout my medical training and career. As you think about life in the physical space, you can learn and gain insights all the way from the tissue level to the cellular, molecular, atomic, and subatomic levels.

But the physical realm is not limited to our understanding of patients. We too, as physicians, live in this physical realm. We too are constrained by the laws of physics and physiology. We too experience the benefits and consequences of our life choices. We are stewards of our knowledge of biological life. It is my firm belief that we as physicians ought to model for our patients what healthy living looks like. Just as we would expect our accountants to manage their own money wisely, lawyers to live within the constraints of the law, and pastors to live according to biblical truth, physicians should be healthy. I understand that there are a lot of disagreements around certain diagnostics and therapeutics, but when it comes to the basics of healthy living - nutrition, fitness, weight management - we need to lead.

Professional

The final area is the professional. The word professional carries the connotation of one who is skilled in a particular craft - who has dedicated themselves to the mastery of an art. It stems from the Latin profiteri, which means to declare publicly. It is one who professes a mastery of a certain skill. With that mastery comes certain expectations - expectations of competence and decorum. This is the practical expression of excellence applied to the craft.

In medicine, one of the fundamental, but not frequently discussed, aspects of professionalism is the idea of a fiduciary relationship. We hold up the doctor-patient relationship as sacrosanct - and rightly so.

Several years ago, I attended a conference. The keynote speaker gave a beautiful lecture on the nature of the patient-physician relationship. In this place, the patient comes to a physician requesting assistance or assurance regarding her health. In the process, the patient reveals very personal details about her life and body, trusting that the physician will guard with appropriate propriety the things that are shared. And in exchange, the physician offers, in good faith, his best assessment and engages in the best course of action.

Unfortunately, there are many forces that want to invade the sanctity of the patient/physician space. Payers want to make sure that costs are contained. Regulators want to enforce standards of medical practice. Administrators want to help their organizations turn a profit. Suddenly, the exam room becomes quite a crowded place. And the allegiance of the physician is pulled in often divergent directions. In the midst of all the noise and competing interests, we as physicians need to remember to keep as our grounding focus our fiduciary relationship and obligations to the patient. That is excellence in medicine.