American College of Physicians: Internal Medicine — Doctors for Adults ®


The path to attaining a 'virtuous' professional life

From the February ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By William J. Hall, FACP

Can you tell me, Socrates, is virtue something that can be taught?

I was passing through the emergency room one night on my way to see a newly admitted patient only because it provided a convenient shortcut to the wards. I couldn't help noticing the clown sitting on the edge of a chair in the waiting room.

She had apparently been rubbing her eyes and in the process had smeared her makeup and displaced her bulbous red nosepiece. While grieving individuals are common in that setting, I didn't usually find them garbed in billowing pantaloons and oversized shoes.

I assumed she was a member of the volunteer troupe of clowns who frequently visit our hospitalized pediatric patients. I remember thinking that for an amateur, she creditably imitated the hobo clown, Emmett Kelly. I hurried on my way.

The next morning, I visited a patient I had admitted the previous night. Much to my surprise, I found the grieving clown curled up in a chair at the bedside of the other patient in the semi-private room. She looked somewhat worse because of what had obviously been a long night.

The make up was even more smeared, her shoes were off and her red nose was wrapped around the wrist of the very ill young woman in the bed. The patient, I learned, was the clown's daughter and had been admitted from the emergency room with a serious relapse of a chronic illness.

Mistaken assumptions

Since then, I have thought a great deal about my reaction, or more appropriately, my lack of reaction to this human being. No, I had not misread an ECG or mistakenly written a prescription for a lethal dose of a medication. I had instead reached a premature conclusion while sizing up a fellow human being in distress, which is the antithesis of what I have always felt is a defining characteristic of internists. My assumption about this person, based on nothing more than clothing, had muddled my powers of observation.

I have subsequently thought about other situations in which I may have made similar mistakes with my own patients. We have countless opportunities to miss important clues from our patients when we provide end-of-life care, evaluate elusive symptoms and make assumptions about medication adherence.

If clothing alone can create such a misperception, how do my personal values about gender, race, social status and age cause similar misjudgments? More importantly, in the complex roles internists play, how can we make sure we have and maintain objectivity as one of our professional competencies?

The right thing

Our Canadian colleagues may offer some help. I recently met Nuala Kenny, MD, a physician-bioethicist from Dalhousie University at a meeting of the Royal College of Physicians and Surgeons of Canada. She is working on an ambitious enterprise known as the Canadian Medical Education Direction for Specialists 2000 Project, which seeks to define the scope of maintaining professional competencies among Canadian physicians. Researchers are evaluating medicine's central competencies, including how physicians maintain effective communication skills with patients in light of the growing influence of science and technology.

Dr. Kenny points out that at no time in our history has the doctor-patient relationship been more crucial to the delivery of care. Our observational and communication skills are shaped not only by our training but also by the personal values we bring to this relationship. Our impact on patients is determined as much by who we are as it is by what we know. It is therefore critical to understand our own values that guide our communication with patients.

Dr. Kenny uses an unfashionable word—virtue—to describe these personal values. In this context, virtue refers to our essential character traits that predispose us to do the right thing in our relationships with patients. She purposely uses the classic Aristotelian definition of virtue that has led to the normative ethical standards in the West.

In the language of informatics, virtue is our operating system, which functions synergistically with—but also apart from—microprocessor speed and memory. Just as with our laptop computers, personal operating systems require virus protection, and they benefit from frequent updates.

Professional virtue

But how can we actually assess—and improve when necessary—the character traits that lead to the correct application of virtue? In analyzing virtue, after all, we can't easily use any known testing schema or standardized process.

Dr. Kenny suggests that a "virtuous" professional life can be attained only through a combination of continual self-reflection and learning from role models. This process, she says, is essential to ensure that our communication with patients produces the right kind of results.

Leading the virtuous life is a life-long process in which we should improve with age. None of the current strategies for maintaining competency address this aspect of doctoring.

I think I have discovered one effective method, however. In my travels around the country this year to regional ACP-ASIM chapter meetings, I have met many virtuous physicians, only a tiny fraction of whom I have featured in these monthly essays. These individuals have already become role models to me, even though I have had only very brief contact with them. I cannot imagine how we could continue to improve our personal operating systems for virtue without establishing relationships with similar internists active in every community.

One thing is clear to me: We can best maintain these relationships through educational meetings and joint projects. And the College, of course, is the venue for this critical form of continuing education, which may be the most important member benefit of all.

My clown acquaintance left her red nosepiece in the hospital room after her daughter had been discharged. Violating at least a few rules of hygiene, I slipped it into my pocket, and it now sits on my office desk. It serves as a gentle reminder that while clothes do not make the patient, they can confuse the doctor.


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