Humility: “Humility and the practice of medicine: tasting humble pie”
While doing some research to find inspiration and sources for a piece on humility, I came across this paper titled “Humility and the practice of medicine: tasting humble pie”. It was written in 2010 by Harvey Max Chochinov, MD PhD, Canada Research Chair in Palliative Care. It was originally published in the Canadian Medical Association Journal. Once I read it, I fell back on the motto “don’t reinvent the wheel.” It summed up everything I wanted to say about humility in medicine. While this piece is written from the viewpoint of a physician, it is easy to see how this applies to prehospital medicine as well. With Dr. Chochinov’s permission, it is shared below:
“As Scottish author J.M. Barrie wrote, “Life is a long lesson in humility.” At first glance, the topics of medicine and humility would seem an unlikely pairing. After all, training for certainty in the practice of medicine — the slow but steady relinquishment of humility — begins in medical school.
Along the way, ignorance is replaced by knowledge and doubt with assurance. In his book The Silent World of Doctor and Patient, Jay Katz states: “Socialization of physicians reinforces the universal human tendency to turn away from uncertainty,” letting physicians assume a role as “the bearers of certainty.”
But to be humble means to appreciate the limits of your abilities, understanding and importance. For physicians, humility distinguishes between knowing what illness the patient has and what it means, and understanding how it feels to have it. Humility differentiates what is clinically indicated from what treatment choices patients deem appropriate; it also separates knowing what should happen within specified clinical circumstances from what does happen.
Sir William Osler understood that while some things can be known, others must be inferred or experienced. One morning, Osler was discovered by a colleague, “struggling in the effort to pass a stomach tube upon himself, resulting in the ordinary gagging and retching which such a procedure produces in one unaccustomed to it. When asked what he was doing, he replied: “Well, we often pass these on people, and I thought we ought to find out what it feels like ourselves.” Wisdom led Osler to appreciate those things that characterize human vulnerability and patienthood; humility helped him understand that there are aspects of human suffering that are not easily penetrable. “This grace of humility,” Osler wrote, “is a precious gift.”
Years later, Osler protégé Harvey Cushing discovered first-hand the challenges of becoming a patient when he was admitted to hospital for the treatment of severe vascular disease. He bemoaned that “a man deprived of his pants gives up not only independence but identity —even hope.” In his cryptic way, Cushing was conceding his humility, by acknowledging that the very essence of who we are and our perceived place in this world is soluble within patienthood.
For Cushing, being a patient was a bitter and personal affront. For Osler, it was the cornerstone of compassionate care.
Illness, or even the threat of illness, imposes a state of vulnerability that can undermine a person’s sense of self. How physicians see patients or, more specifically, how patients perceive themselves to be seen can influence their sense of dignity. We should think of ourselves as mirrors, where patients seek some positive reflection or affirmation of self. Providing this to patients requires humility. If all we see is the illness, patients may feel that the essence of who they are is being overlooked. If we are distracted, patients may feel unworthy of our attention; if we are too rushed, patients may feel undeserving of our time. And if we deem ourselves more important, patients may feel they are unimportant.
Humility can also facilitate the relinquishment of certainty, which all too often, as Katz writes in The Silent World, serves the purpose of “maintaining professional power and control over the medical decision-making process as well as of maintaining an aura of infallibility.” Absolute certainty leaves little room for shared decision-making. Acknowledging medical uncertainty invites dialogue, providing patients a greater voice in the decision-making process. Physicians who lack humility talk at their patients; physicians who are sufficiently humble talk with their patients. Talking or partnering with patients can promote empathic connections, which may decrease the risk of physician burnout and enhance the likelihood of job satisfaction.
Like wisdom, humility is not easy to come by. Many patients want to feel that their physician is in control of their disease and have little interest in shared decision-making. Physicians may sense that admitting uncertainty, even to themselves, feels like a breach in their obligation to provide care. Because of the enormous responsibility that comes with the job of doctoring, anxiety is not unusual; admitting one’s shortcomings may not salve this anxiety and may even intensify it.4 Being humble, however, does not mean embracing mediocrity or indecision, any more than clinical confidence need be conflated with arrogance or hubris. And being uncertain does not mean being incompetent. Humility, in fact, is a key driver that commits physicians to the continuous pursuit of knowledge.
Perhaps most humbling of all is accepting that anyone can make a mistake. The emotional toll for physicians involved in medical errors can be profound, and include feelings of guilt, depression, fear and loss of confidence. While this can happen to any physician, most worrisome are those who don’t know what they don’t know. Little wonder that competence, as measured by performance on licensure examinations, correlates with a greater likelihood of referring patients for consultation.5 Clearly, the humility of knowing one’s limitations is an important element of competence. This awareness enables physicians to recognize and respect the expertise of others — a cornerstone of gratifying collegial relationships and well-functioning multidisciplinary teams.
The nature of knowledge is impossible to contemplate or grasp in its entirety. In the face of new discoveries and insights, today’s medical wisdom may be destined to become yesterday’s folly. (The strychnine injections Osler received on his deathbed — at the time a standard practice — are now known to be entirely useless.) The epistemological implications for those who practice medicine are critical. Physicians must be prepared to challenge fundamental assumptions and examine their practice patterns; they must consider credible evidence and be open to change. Humility dictates that no matter how great the measure of our reach, we acknowledge the limitations of our grasp.
The truth is that everyone, including those we love, confronts health crises; no one is immune. Those of us whose practice can be measured in decades have watched our revered and once powerful mentors grow old and may have helped care for some through their final days of life. Feelings of invincibility are replaced by the realization that patienthood can arrive instantaneously; and that it does not discriminate based on perceived status or power. Indeed, perhaps nothing promotes humility more effectively than the growing realization that little separates us from our patients. Typical of Cushing’s experience, the cultivation of humility is often painful and requires a high level of self-awareness and reflective practice.
Within the profession of medicine, there is nothing simple about humble pie; but consider taking a bite — it could very well change the way you practice medicine.”
Citation:
Chochinov HM. Humility and the practice of medicine: tasting humble pie. CMAJ. 2010 Aug 10;182(11):1217-8.
