You can't put metrics on purpose and resilience

An unusually calm morning in the ICU led our amiable attending start rounds by asking how we took care of ourselves so that we could look after others. While scrambling to gather patient details, we all struggled to answer them, except for my eccentric British-Canadian friend (who is still confused about his nationality since Brexit) who said he did so by reading Hemingway.

In medical school, board scores seem to be the primary pursuit, along with the most coveted specialty (also the one with the highest remuneration) — since we are subconsciously groomed to be overarching achievers. We toil to actualize these goals and ignore so many aspects that are needed to keep the “human” alive. No one teaches us about how to actually nurture ourselves so that we can do right by the next person we treat.

This cultivated ambition has produced marvelous research and helped us march into the future with a certainty of being able to overcome what we previously considered fatal. But as we press on one side of human nature, the other gets ensnared in its luminescence.

David Brooks, in his book Road to Character, describes these two opposing sides of nature — the two Adams (which was first described by Soloveitchik’s “Lonely Man of Faith”). Adam I is the career-oriented, ambitious side of nature. He wants to build, create and discover along with achieving a high status and win victories. Adam II, on the other hand, is the one that wants to embody moral qualities. He wants to sacrifice “self” in the service of others. Our culture in medicine has focussed excessively on Adam I.

Adam II has been left to fend for himself, and the disillusionment has ensued. The system, malpractice worries, paperwork and, of course, chronic entanglement with the electronic health record, have exacerbated our disconnect with Adam II.

I was discussing this with a physician at my institution — a stalwart of medicine for 50 years and witness to changing tides of the profession. He mentioned that as young trainees, there was an emphasis on idealism and collective sense of purpose as a society. We had roles that started in the family and gave us our first lessons in building the Adam II and that translated into carrying these ever-developing attributes into work. As individualism and nuclear families (or even growing human disconnect) have been flourishing, our roles have dissolved, and our moral compass is in disarray. Harvard sociologist Zimmerman, in his book “Family and Civilization,” demonstrates causal connections between the rise and fall of different types of families and civilizations.

A loss of relatedness renders a state of perpetual chaos. Prominent psychologists Deci and Ryan in the “American Psychologist,” reckon that relatedness, being one of three innate psychological needs (other than autonomy and competence), if thwarted can lead to loss of motivation, productivity and happiness.

It bothers me to see friends from medical school, brimming with purpose in their early years, slowly drift towards an abyss of cynicism. I would initially conclude this was not rampant (given my cohort size lacked statistical power), but studies showed increases in empathy during early student years and then significant declines when the same students entered clinical practice. Medical school is challenging, but it is a protected environment. It is akin to training in the barracks: rigor and discipline being a constant, but real character is born on the frontline looking after patients and colleagues.

The antidote

One evening, while the Beatles song “With a Little Help from my Friends” played in the background, I realized that the reason why I persisted despite frequent setbacks was because I had great mentors along the way. They were like beacons when the inevitable waves of hindrance nearly steered me adrift. Mentoring programs need to proliferate throughout medical post graduate programs. It is these mentors who invoke our thinking into realms that we are apprehensive to explore.

Residency is the most challenging period in a doctors career. It is that epoch, where you are thrusted into an orbit of responsibility from ground zero and the pressure to perform is at the zenith. It is the period that turns most idealists into cynics. This is where the most important chance lies to preserve the Adam II. It is here when humanism should be imbibed and in the process, keep the reflection of our purpose alive. It is our innate nature to seek purpose constantly the loss of that can pummel our contentment, and the infamous burnout is thrust into limelight. Through the trajectory of time, it is purpose that has helped withstand adversity, thereby, nurturing resilience — a trait that medical leaders have been most recently advocating.

It is up to us individually to preserve our purpose. We are products of our environment. It is the people whom our lives have intersected with have been part of our inspiration. We may get bogged down with all of the turmoil that surrounds us — forgetting about those people, but make time to see them and make an effort to be present. This will keep the fervor alive and kicking.

The great football coach, Nick Saban, encourages players not to worry about winning the championship, instead concentrate on making the day of training impeccable. We become so obsessed about the potential eventualities of life that the present goes unnoticed and soon life is like groundhog day. It is the here and now. And if done well, it will lead us to better.

We have become maniacally focused on measuring things and ape our peers in management. “You can’t manage something if you can’t measure it.” But it is herein where the problem lies: you cannot put metrics on relatedness, purpose and resilience (scale of 1 to 10 anyone?). These aspects are influenced by multiple factors, and it’s more like an all-or-none phenomenon. In the end, it is at the confluence of Adam I and Adam II, that great patient care will manifest.