Medicine at the Crossroads

A Collection of Stories and Conversations to Forge a Vision for Health Care

Michael Attas

• Publisher: Stellar Communications
• Year: 2018
• ISBN:
  9781944952235
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Stories and Conversations to Forge a Vision for Health Care

Medicine at the Crossroads is a collection of essays based a column originally published in the Waco-Tribune Herald by renowned cardiologist Dr. Michael Attas. It touches on three perspectives – the physician, the patient, and the healthcare system – and addresses some of the most pressing questions in medicine today. Individually, each story of illness, medicine, and healing provides a tiny, fragmented glimpse into the heart of a problem. Collectively, it is Dr. Attas’s hope that these stories forge together to reveal a larger narrative truth.

The collection originated among scores of bright, inquisitive students in the classrooms of Baylor University, where Dr. Attas founded the Medical Humanities Program. The program was the first of its kind in the United States, and it redefined how students prepare for a career in health care. Dr. Attas and his students explored medicine and the human condition through stories of brokenness and redemption, pain and loss, and joy and despair.

But the stories that have emerged from Dr. Attas’s 40-year career are not just for students. The conversations are for all of us. Whether you are a physician, patient, or other participant in the healthcare system, may you be bold enough, humble enough, and vulnerable enough to listen to these stories—and to the stories of those around you—with wonder and awe.

While this collection may offer some solutions with “fear and trembling, ” it does not dare claim to have all the answers. The purpose is simply to start conversations. So, let us take a collective breath and examine our personal feelings and expectations of medicine. May we each glimpse the possibilities and discover our own fresh, creative solutions.

Ultimately, the purpose of Medicine at the Crossroads is to help us find our way to compassionate, humane health care for all. Together, may we find healing—for ourselves, our loved ones, and our system.

What leaders are saying

“For years, Dr. Attas has been prescient about changes in medicine and the physician’s role. In a time of radical change in health care, when the very practice of medicine is in question, he shows us that the essential relationship is between the patient and the physician.”

– United States Ambassador Lyndon L. Olson, Jr.

“Candid, transparent, and provocative, this is a “stained glass” collection of stories for talking about health care through the lens of the medical humanities, helping us understand how the science and art of medicine intersect. A must-read for anyone entering or serving in health care.”

– Joel T. Allison, FACHE, Retired CEO, Baylor Scott and White Health; Senior Advisor, Robbins Institute for Health Policy and Leadership

“Dr. Attas reclaims a

THE

PHYSICIAN

“In seeking absolute truth, we aim at the unattainable and must be content with broken portions.”

—WILLIAM OSLER

THE PARADOX OF SERVICE

Is service enough of a reason to be in medicine?

Let me ask you a question: why are you in medicine?

When I ask my students this question, I hear all sorts of reasons why they choose this profession. Some, for example, choose it for financial gain. I tell them that if they want to make a lot of money, they’re in the wrong building. They need to transfer to the business school. I say this because if they view medicine as only a business, they’ll be left adrift when the business model changes, as it inevitably will.

Some choose medicine for pride and prestige. But as far as prestige is concerned, the days are over when physicians and pastors topped the lists of respected jobs. The prestige of health care, at least according to public perception, has plummeted in survey after survey, and often for valid reasons.

Others choose this profession because they are skilled in the sciences and problem-solving. They say they enjoy the intellectual or technical challenge. But humans are more than problems to be solved. We are mysteries to be lived and experienced. We’re relational beings with stories and realities and illnesses. In some aspects, we are all broken and wounded. The vulnerability that comes with that is what finally brings a patient to our offices or hospitals. Bearing the gift of trust given us by our patients can be a demanding and daunting task—one that is not fully accomplished by the sciences. Those who view medicine as strictly problem-solving will find themselves at an emotional rock bottom when the science fails.

While we certainly need to excel in our technical skills and business understandings, we must possess a greater motivation to commit to a life in medicine. In spite of these faulty reasons for entering the profession, I would venture that, at some level, most people buy into the notion of service.

But is service enough of a reason to go into medicine?

Even for those of us who are motivated by service, the outcomes are looking bleak. Study after study shows that satisfaction scores are at an all-time low both for patients and providers. Physicians are burning out early and retiring at younger and younger ages. Nurses are in danger of becoming jaded and callous. Rather than embracing radical changes and challenges of the status quo, many of us are fearful. We’re plunging headlong toward a major shortage of physicians in this country, and we can ill afford to lose any more of the best and the brightest. If this trend isn’t reversed, we are heading off of the cliff in the way we all experience medicine and illness.

To break this decline within our healthcare community, we need to take a closer look at our reasons for going into medicine. In particular, we need to take a closer look at our notion of service.

In a letter to one of the earliest Christian churches, an apostle named Paul used the word “kenosis” to describe service.¹ “Kenosis” may be a single Greek word, but it contains an entirely rich, existential perspective of life. It refers to a “self-emptying” sacrificial love.

In true kenosis, each of us is a vessel full of love that we empty and then refill. It is considered by some as a model for not only human and religious behavior, but for the notion of vocation in certain fields. Indeed, for those in the healing professions, kenosis is the bedrock of our history.

Here is where a paradox occurs: when our vessels of love are emptied, we are refilled again by acts of loving service to others. Kenosis is a continual, unbroken circle of being refilled by first being emptied.

Herein lies a problem in medicine: many healthcare providers resist this true notion of service. They don’t allow their vessels to run dry. “Don’t get involved in patients’ lives,” they reason with themselves. “The emotional cost is too high.” They focus only on the medical issues, expecting science do its magic. For them, medicine isn’t about service; it’s about biomedical problem-solving.

But there’s a danger in emptying our vessels dry and not filling them back up again—or refilling them with the wrong things. This is partly the reason physicians have higher incidences of suicides, divorces, substance abuse, and depression than the general population. I believe the rejection of kenosis is responsible for the high anxiety among health care professionals.

At this point in history, it is more important than ever to honestly identify our reasons for going into medicine. A primary desire for wealth, prestige, or problem-solving is not enough to bear the demands of medicine. Without an understanding of kenosis, we won’t be able to meet our patients’ deepest needs. It is only this kind of self-emptying service that will gratify their needs—as well as our own.

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1New American Standard Bible © 1995, Philippians 2:7.

SHADES OF GRAY

How can we be certain about life-and-death decisions in a world of uncertainty?

We seem to live in a world of certainty, of black and white. That’s why respect for nuanced differences of opinion and civilized discourse is fading at all levels of society—and nowhere is this problem more apparent than in the academic classroom. Students often arrive at medical school with firmly held religious and political beliefs, many of which they’ve inherited from their parents. They see ambiguity as a weakness; there are no shades of gray in their beliefs.

But in the world of biomedical ethics, human dilemmas are always couched in just such shades. Here, the certainty of youth invariably bumps up against the hard reality of very human problems and patients—like the 16-year-old that arrived in the emergency room where I was on duty.

She was an unwed mother who had delivered a beautiful baby girl, and now she was desperately short of breath. Within twelve hours she was on life support. She had a form of congestive heart failure and was rapidly declining, so in an effort to stave off an almost-certain heart transplant, we installed a heart-assist pump to rest her heart until a suitable donor could be found. But after a few weeks, her heart miraculously began to slowly recover. Eventually she stabilized, went home, and recovered perfectly. She resumed her high school studies and graduated with honors.

But one year later, while a student at college, she became pregnant again, which threatened her life once more. We were left with Solomon’s dilemma. On the one hand, carrying the pregnancy to term would almost certainly lead to two deaths: hers and that of her unborn child. Furthermore, no one in her community was willing to take responsibility for her first child, who would be left orphaned. On the other hand, terminating the pregnancy obviously would result in the death of an unborn child while saving the life of the mother, and this option was against her religious beliefs.

Do we sacrifice a life in the name of principles? Who decides? And upon what moral or political or theological basis is that decision to be made?

When I present the case of this young mother to students, it inevitably causes an uproar. Students argue passionately with each other. Some weep at the injustice of reality. All are astounded that physicians have to guide people gently to a place of healing where no “choice” is ideal.

These students are learning that ambiguity is simply an acknowledgment of human frailty, and that medical ethics is not math or rocket science. They’re realizing that, more often than not, there truly isn’t a right answer. The answers are usually shrouded in mystery and ambiguity, leaving people wounded in its wake. Students who were radically pro-life suddenly realize that choices of life and death are complex, and students who are pro-choice realize the choice itself is costly. And it’s only the beginning: in this profession, they will witness the most painful of human choices, and the decisions will never be easy.

Never is a dilemma more intense than when considering euthanasia. I bring this issue to light in the classroom by reading a first-person account published in the Journal of the American Medical Association in 1988. It was written by an anonymous intern who was caring for a woman dying of metastatic cancer.

The patient was in horrible, unrelenting pain because the pain relief was not working any longer. She had no more than a few days or weeks to live. One night, in agony and despair, the woman pleaded with the intern, “Let’s get this over with.”

Out of deep frustration and compassion, the intern brought a terminal dose of narcotics into the room. When her rate of breathing slowed and then ceased, he said, “It’s over, Debbie.”²

These words have become one of the most famous lines in medical ethics literature. While not explicitly saying so, the Journal of the American Medical Association made it clear that he had helped the woman end life on her terms.

As expected, the article created a firestorm in medical, legal, and ethical worlds. The case was an example of what is now called active, voluntary euthanasia. It’s when a patient in a hopelessly terminal case –and with full, informed consent—simply requests help in dying. It is an active, free choice.

At that time, participating in what is now called physician-assisted suicide was illegal nationwide, as it still is in many states. Many prosecutors promised to bring charges of homicide against the intern if they could discover his identity, which the publication did not reveal. This was before the Kevorkian era, when a handful of pioneering states and ethicists began to present euthanasia and physician-assisted suicide as reasonable choices that people of faith and strong morality could openly discuss. They were talking about death with dignity, though it was not something that many spoke of in public. If it were discussed, the subject was never intended to leave the door open for healthcare professionals to expedite a patient’s demise.

But this discussion needs to be placed in the context of other forms of euthanasia. Active, involuntary euthanasia, for example, is supported by a majority of Americans when it takes the form of capital punishment in the justice system. Another form that is requested by some terminally ill patients and their families is passive euthanasia, which is the withholding of treatment. A respirator, for instance, is disconnected from a brain-dead patient, and the decision is made to withhold intravenous fluids or antibiotics. Passive euthanasia is about letting nature take its course. In this regard, we could say that euthanasia is a part of every hospital in the country when we consider that most Americans now have “advanced medical directives” that guide healthcare professionals through the ethical quagmire of end-of-life decisions.

Even in the context of these other forms of euthanasia, for many of us there is something still profoundly disturbing about helping a person end life, even when the patient’s days are limited. It tugs not only at our emotional heartstrings but also our sense of ethical and religious norms and values. It gets at the heart of what our civilization stands for.

Given all of these profoundly complex issues, how can we be certain about life-and-death decisions in a world of uncertainty?

We can begin by examining the goals and values of our religious traditions and by defining our highest value. I believe that a goal shared by many religious traditions is the relief of suffering based on compassionate love. I would also submit that biological life, while important, can be worshipped to the point of idolatry.

When we insist, for instance, on prolonging life at all costs, we seem to be placing our own needs and beliefs above that of our patients’. Preservation of life at the expense of dignity and freedom is often a misguided attempt to deny our patients something they all want: the freedom to choose the terms of their passing from this world. Extending the life of a person whose suffering is agonizing seems almost inhumane and narcissistic of us as healers; we often treat our pets with more dignity and compassion.

While I may not know the best answer to such medical ethical issues, I believe euthanasia is an act that can indeed be performed out of profound love and respect for human life and dignity. For me, it is consistent with my own religious tradition and faith, though others may vehemently disagree.

Which brings me to my next point: as we grapple with these profound dilemmas, we must not leave these conversations solely to politicians, protesters, or academic ethicists. We should strive to discuss our opinions with each other with respect and civility. Our classrooms should be the places where young adults can explore their belief systems and work out their understanding of complex issues.

And more than anything, we must accept that this world is never as simple as it seems. Because until you have had a dying young woman weep in your arms about the choices she faces, you cannot begin to imagine the complexity of those decisions. It is only with this humble perspective that we can gently walk our patients into those dark places, providing non-judgmental love, light, and...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword by Judge Ken Starr
• A Perspective from a Physician-in-Training
• Introduction
• Acknowledgments
• Physician
• Patient
• Healthcare System
• A Letter to the Next Generation
• Bibliography
• About the Author