The Challenges of Modern Medicine

Some thoughts from my recent visit to the Mayo Clinic (as speaker, not patient)

Presenting at the Mayo Clinic (photo courtesy of Mayo)

This past week, I had the privilege of speaking to a gathering of medical professionals hosted by the Mayo Clinic Program in Professionalism and Values. As I noted in an earlier post, I have been pleasantly surprised by interest from medical professionals in my work on difference and disagreement.

My task at Mayo was to frame the day with remarks on “Contemporary Challenges to Professionalism: The importance of organizational purpose, values, and mission.” I then offered reflections throughout the day on issues and perspectives that emerged from various discussions.

The conference took place on Mayo’s campus in Rochester, Minnesota. It included institutional leaders from Baylor, University of Chicago, University of Colorado, Dartmouth, Dell (University of Texas), Duke, HCA Healthcare, Mayo Clinic, Medical College of Wisconsin, Stanford, UCLA, UCSF Health, and Yale, as well as colleagues from Washington University.

In today’s post, I will summarize my initial comments and then share some of my impressions from my day with the doctors (and other professionals).

Disagreement in Medicine

I began by observing that the practice of medicine is not immune from the deep disagreements that plague contemporary society: disagreements between individual clinicians and their supervisors, disagreements between healthcare professionals, and disagreements between clinicians and their patients. As I noted in an earlier post, the medical profession “must routinely bridge those differences to succeed in high-pressure situations where lives are literally at stake.” And on the ground, medical teams usually demonstrate a functional and pragmatic ability to work together. As my friend Eboo Patel notes, “to date, not one [medical professional] has said they would walk out of the operating room” over an ideological disagreement.

But in some ways, the operating room might be one of the easiest places for medical professionals to put aside their disagreements. Things get harder when it comes to laws and policies governing how doctors care for patients—for example, if a physician refuses to care for an unvaccinated person or declines to perform elective transgender surgery.

Another example comes from competing views over the appropriate amount of attention to Diversity, Equity, and Inclusion (DEI) concerns in medicine. On this issue, professional competence is at risk from both political extremes. On the one hand, some conservative commentators who would reject any role for DEI discussions in medical training are ultimately imposing barriers to patient care and neglecting important systemic barriers to medical practice. On the other hand, the core of medical expertise is not activism, and while some medical professionals advocate for greater activism, there are ways in which this can be counterproductive. For example, during the height of the COVID-19 pandemic, some medical professionals walked back their social distancing and other precautionary advice during the George Floyd protests. The spread of the virus in large gatherings did not depend on which issues people gathered to discuss, and the implication that medical advice should shift based on the ideological flavor of a gathering undercut professional credibility.

The Importance of Purpose, Mission, and Values

After canvassing some of these disagreements within medicine, I suggested some individual practices and postures that could help move toward better understanding and better disagreement. I then shifted to three ways that institutions can help facilitate these ends: knowing who you are, being who you are, and by giving grace at the edges.

Knowing who you are means being clear about purpose and values. Organizational values today are often stated at the level of vague generalities like “pursuing excellence” or “preparing tomorrow’s leaders.” But meaningful values that shape organizational culture flow from a clear articulation of purpose. That’s because purpose sets priorities and boundaries. By definition, purpose constrains by providing guidance for what an organization does and, just as importantly, for what an organization does not do. When purpose is clear, unaligned activities and personnel will not dominate agendas or move the organization away from its primary mission. Clarity of purpose also allows organizational actors to focus on achieving common ground goals despite their differences. If you are a teaching hospital, then one of your primary purposes is educating future health care professionals, and that mission should help you set priorities and boundaries.

Being who you are means embodying purpose and values in words and actions, even when it’s difficult. For example, if a medical school says it values academic freedom in support of its research mission, then that value should be made clear to its internal and external audiences. Sometimes, enacting purpose means saying no to otherwise attractive possibilities. During my time visiting Mayo, I heard several references to a quote by one of the Franciscan founders of the institution, Sister Generose Gervais: “no money, no mission.” I wondered aloud if this might be a misleading dichotomy. Of course, any mission-oriented organization needs money to survive. But the question for most organizations isn’t really “no money”—it’s how much is enough? I suggested that a more purpose-oriented mantra might be “less money, better mission.”

Giving grace at the edges means putting common ground institutional objectives before differences. Whatever you establish as the boundaries of your institution, make sure you will stand behind and support the people committed to operating within those boundaries even when—and especially when—you disagree with them. Mayo Clinic’s mission is “inspiring hope and promoting health through integrated clinical practice, education and research.” In the context of that mission, most employees will see how they and others support that mission, regardless of individual political, religious, or other beliefs. That doesn’t mean you won’t have really deep differences or that these differences won’t matter. You will and they do. But if those differences do not affect your ability to execute your core mission, they should not be used to exclude people or viewpoints from your organization. That means you will need to find ways of viewing the people who see the world in fundamentally different ways as wrong or mistaken rather than as evil.

Unsettling Similarities Between Medicine and Law

Much of the discussion with medical professionals at the Mayo gathering reminded me of similar conversations in law school settings. On reflection, this is not surprising—both law and medicine require rigorous credentialing and training processes followed by what are often extremely consuming and demanding early professional settings.

Unfortunately, both law and medicine have high burnout rates, especially among younger practitioners. Some of this is no doubt due to the grueling professional demands that are not meant for everyone. But my hunch is that these challenges are exacerbated by the lack of institutional purpose that I mentioned earlier in this post.

Most doctors and lawyers I know—and most students aspiring to those professions—are drawn to these career fields because of their desire to help people and help society. At their healthiest, law and medicine play vital roles in peacekeeping and healing. But when they lose their sense of purpose—their true north—both disciplines can quickly become deflating and disorienting.

My sense is that purpose is threatened in both law and medicine in two discrete ways. The first is more easily identifiable: the bottom line. When institutions become driven by efficiency and dollars (“more money, less clear mission”), they can lose touch with their higher purpose and calling.

The second threat to purpose in law and medicine is harder to discern but perhaps even more threatening than profit motives: the fraying consensus around core values like “seek justice” (in law) and “do no harm” (in medicine). With respect to the latter, Warren Kinghorn and colleagues have observed that “professional virtues depend on particular moral community traditions to undergird and sustain them” and “attempts to ground these virtues in narratives intrinsic to medical practice—in the moral consensus of physicians or patients, in the self-regulating character of medicine as a profession, in the Hippocratic tradition, or in the physician–patient encounter—have been unsuccessful.”

Neither law nor medicine has ever fully embraced a form of excellence that overcame all biases, vices, and self-interest. But there was a time when there was at least a general consensus among most practitioners about the meaning of “justice” and “harm.” The loss of that consensus will only undergird the profit motive. And absent large-scale changes, I worry that the burnout will continue among the best and brightest of our future legal and medical professionals.

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Today seems like a good day for my occasional reminder that this newsletter is not tied to the news cycle, there is a lot going on in the world right now, and you should focus your attention on what’s important in your life.