Philosophy in Medicine

Philosophy's place in medicine, and what does it mean to find your personal “why”.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. John Yoon talking about philosophy in medicine.

[00:00:10] Dr. Yoon: Is this really medicine? Is this what I thought I was getting myself into? And it was actually that sort of trying to figure out that existential crisis of like, what am I actually, am I actually caring for patients or am I sort of kind of managing a system? Am I really a physician who is trying to work for the good of the patient or am I sort of an RVU-generating pawn in a medical-industrial complex?

[00:00:35] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. John Yoon. Dr. Yoon is an associate professor of medicine at the University of Chicago, an academic hospitalist, and a medical educator. Dr. Yoon's primary research interests involve the fields of virtue, ethics, vocation in medicine, and the moral and professional formation of physicians. He was co-investigator on the Project on the Good Physician, a recently completed longitudinal study of medical students funded by the New Science of Virtues Project at the University of Chicago. Dr. Yoon is also associate faculty at the MacLean Center for Clinical Medical Ethics, faculty scholar for the Program on Medicine and Religion, and a junior faculty scholar of the Bucksbaum Institute for Clinical Excellence. John, thank you so much for joining me today.

[00:01:33] Dr. Yoon: Oh, you bet. Thank you for this invitation.

[00:01:36] Dr. Cifu: So recently, you've been working in the Philosophies of Medical Education Transformation Laboratory which goes by the acronym PMETL, which is like the coolest acronym in the world. You'll tell me if it's a cooler acronym than what it actually stands for. Can you just tell me a little bit about it? Like how did this get its start and what, I guess, generally are the goals?

[00:01:55] Dr. Yoon: Yeah, yeah. Well, my involvement with PMETL has been kind of serendipitous and very fortunate in my career but it's a laboratory filled with philosophers and clinicians, medical educators who care about wanting to transform medical education for the good of the patient.

It's housed in the Kern Institute which is actually a little bit similar with the Bucksbaum Institute in that it wants to help develop professionals who care about the doctor-patient relationship. And their focus is primarily rooted in character, caring, and excellence. So the PMETLab is functioning as sort of a foundational arm of the Kern Institute, helping medical educators think through conceptual groundings of all their initiatives so that it's like thinking about if you're cultivating a plant, you want to make sure you got good soil, right? So that the plant that grows ends up being fruitful. So I think they see themselves as sort of wanting to focus on the good soil.

[00:02:50] Dr. Cifu: It's so interesting because I mean, so often in medical education, we're thinking about, you know, what do we teach people, right? And what we teach people is generally kind of textbooky stuff, right? It's like, okay, here's the physiology you need to know, here's the anatomy you need to know, here are the interviewing skills but it sounds like you guys are thinking about, and correct me if I'm wrong, you know, the people before they get into medicine, and then maybe how to, I don't know, nurture or preserve those people once they're in medicine. Is that kind of right?

[00:03:27] Dr. Yoon: One way to think about it, which is actually very articulately written by Kristin Collier, where she writes this article called, What is Medicine for? And in that article, she makes the distinction between learning to care for human bodies versus learning to care for human persons. And much of, you know, since the flexnerian revolution, much of medical education has been focusing on sort of helping medical students in bioscience and technology to be able to really be able to care for human bodies. But it's really the humanities and philosophy that help orient medical students and future physicians on how we actually engage human persons while we're caring for their bodies. And that's sort of the distinction that I appreciate that something like philosophy and medicine helps kind of reinvigorate as we're thinking about growing as doctors.

[00:04:22] Dr. Cifu: God, I want to sort of circle back to the philosophy issue but first, you know, I feel like we in medicine, and maybe if we just talk about conventional medicine, we've almost, I don't know, either abrogated our responsibility or farmed out the caring for the person in a way, right? We're so dedicated on caring for the body. And I think that's reflected in a lot of else that goes on in America, right? With people seeking care from, you know, celebrity physicians or non-traditional, you know, healthcare providers, let's call it. And so when you guys think of kind of what American medicine is, like, how do you bring that kind of caring back in, you know? Can we bill for it? Like, where does it fit?

[00:05:14] Dr. Yoon: Yeah. I mean, that's in some ways the spark of my journey into this lab, because I would mark the beginning of me thinking about philosophy and medicine actually in a moment in a cramped call room during my internal medicine residency training, where I'm sort of burned out and it's not simply that I'm just tired, but I'm in sort of this existential crisis, thinking like, what am I actually doing, like, here? Is this really medicine? Is this what I thought I was getting myself into? And it was actually that sort of trying to figure out that existential crisis of like, what am I actually, am I actually caring for patients? Or am I sort of kind of managing a ward, managing a system? Am I really a physician who is trying to work for the good of the patient or am I sort of an RVU-generating pawn in a medical-industrial complex? So those types of questions sort of started driving me to like, what was the foundational orientation that actually, you know, trained physicians to think about what it means to care.

And so in some ways, I kind of had to go back to what originally might've been called the medical humanities, but at least when I was growing up, we didn't really have medical humanities. That sort of launched the journey to kind of think about, you know, what kind of different lenses can I start thinking about my practice.

[00:06:34] Dr. Cifu: It sounds like you did more with your existential crisis of residency than most people do 'cause I think it's not that uncommon, right? That as you're pushed in the work and, you know, to some extent the misery that, you know, has always been and remains medical training that a lot of people sort of question, you know, what am I doing?

And I think some people come to, okay, you know, how do I find things of value in what I'm doing? And other people unfortunately do kind of get burnt out and either leave the field or kind of leave part of themselves out of the medical care.

[00:07:18] Dr. Yoon: I mean, granted, everyone has a different why to what they do, you know, and in some ways everyone has to kind of figure out what is going to be their why, even if it's just a matter of like getting through the day and be able to care for my family and having a suitable sort of living. But whatever that why is, it has to sort of ground your work in your sense of meaning. And so I don't judge folks for like, you know, they've chosen this why or that why, but is it going to be the one that's going to allow you to kind of continue in your long, you know, sort of a long-term career?

[00:07:54] Dr. Cifu: So you mentioned philosophy and reading some of the things you wrote prior to meeting here, I was a little lost about sort of like, what does philosophy have to do with medicine or what is even... You know, philosophy stands for a lot, right? Like, what philosophy are you even talking about when you discuss philosophy in medicine?

[00:08:17] Dr. Yoon: I mean, generally speaking, I think of philosophy as sort of the foundational field that helps you have that why. Okay? So in the paper I had mentioned by Kristin Collier, she talks about medicine like building a ship. In philosophy, they talk about sort of there's three components to medicine. There's the science of it, there's the technological aspect of it or the art, and then there's the virtue and the character that comes with it. So medicine's like building a ship in the sense that you sort of first need to ground the foundational materials. That's sort of the science, it helps provide to kind of think about how to build a ship and then there's a know-how in building the ship and that's sort of the art but then you still kind of need a direction where you're headed with this ship and how are you going to steer there, you know? And so Kristin Collier talks about it in terms of philosophy is like the rudder from that ship. Kind of helps you sort of... You know, in connection with some sort of North Star that you're aiming for to help steer the ship in the right direction. So I think of philosophy as it pertains to medicines, helps me clarify my why of what I'm doing as a physician as I'm caring for patients. Again, like for most folks, they have a different type of philosophy that sort of gears them and sometimes it's implicit, sometimes it's unreflective, but they have some kind of philosophy. It's just perhaps sometimes not always articulated.

[00:09:38] Dr. Cifu: Got it. So, you know, you do all this work, right? And you're very productive and involved in sort of a scholarly or academic, you know, thoughtful side, but you're also a clinician, right? You're a busy hospitalist. And so, like, how does this work affect, you know, how you practice as a physician? It's kind of like how you care for people. Do you think about this you know, when you're, I don't know, you know, when you're writing admissions orders, or when you're, maybe more likely, when you're doing that initial H&P on someone?

[00:10:11] Dr. Yoon: Yeah. Yeah. Well, the way I think of it, it's like sort of giving me new eyes to see the same things that I do.

So, one question I had was, well, what's going to sort of move me from, you know, this place where I was in a cramped call room thinking about whether I should continue to be a doctor and thinking about, okay, well, as I was kind of going through some of the literature on burnout, as I was reading through some of the philosophers who helped me kind of diagnose my situation, like, oh, why is healthcare the way it is. You know, why... There's actually sort of like, philosophers thinking about why the modern world is the way it is? Sort of running by the market and all these other social forces that impact what we do as physicians. Even just understanding my situation was sort of helping me to give me that sort of strength to move forward as a physician.

So sometimes it's sort of the unarticulated angst that actually causes burnout, but once you sort of know the diagnosis, then you can kind of like, okay, well this is what modern medicine is. How am I going to now move forward given this reality in such a way that I can sort of keep my conscience clear, do right by my patients, and also maintain sort of a kind of life that my family and my kids would be like, "I'm glad you're a doctor, dad. You didn't burn us on the way," you know? So that's sort of a long way of just sort of helping me to have new eyes to see the same things I'm doing.

[00:11:39] Dr. Cifu: Yeah. That must also, and I know this is part of the work you do, I mean, that must help a lot when you think about, I don't know, either selecting or educating students and trainees because you have a little bit more of that, I don't know, kind of greater understanding of why you're doing this. Is that true?

[00:12:02] Dr. Yoon: I mean, sometimes when I'm with the wards, I ask sort of the students, you know, simple questions like, "Oh, what do you, what kind of specialty you're going to do?" You know, eventually, if I feel the student's open to it, I ask, "So why did you end up being a doctor in the first place?" You know, 'cause part of me wants to query, "What is that why for you?" You know, and inevitably it's connected to some sort of deep commitment by the student, either towards family, towards some sort of social ideal, some sort of philosophical or theological ideal. And so I feel like my role as an educator, I would not be doing right by the student if I were to just let them kind of go through the system, get mangled by it, and hopefully get repaired from it, but if I'm not helping them also preserve that sort of driving moral compass that we all each have, that's shaped by our own traditions that in some ways it's going to sustain our careers. So...

[00:13:03] Dr. Cifu: So I think we all know physicians who seem like they've lost that, right? As they've gone through training and I think it's probably not just medicine. I think it's in every field, right? That you go into something for a reason and by the time you get there, you're kind of done with it in a way. And so I'm not entirely sure it's a problem just in medicine, but I don't really know any other field. So talking about that, you know, do you think it's the fault of how we train people? Or do you think it's the fault of how we select people? That these are people who, I don't know how to say it, you know, if I say, who don't have it in them, that sounds disparaging but it's just that it's not the right field for everybody. And there are people maybe who think it's the right field, but it's not. And once you've invested years of your life and unfortunately, probably hundreds of thousands of dollars, it's hard to turn the ship.

[00:14:07] Dr. Yoon: Yeah. That's in some ways, it's sort of the million dollar question of how do you select the students that in some ways their why aligns with the needs of what we need doctors for, as well as the long-term goals of the profession. I mean, you know, when I was an associate program director, I was facing, you know, residents who you could see, "Oh gosh, why are they doing this?" And they've already invested... You know, they already have $200,000 in debt. And I don't know the answer to that one, Adam, because I think it does behoove us as educators to think about the ways that we present the realities of medicine to future students in such a way that they can be clear-eyed about what they're moving into but without sort of dampening sort of their idealism, that it's going to be this next generation of Gen Z physicians will actually be the ones that change the system in such a way that it actually benefits the patient, benefits the clinicians who are working the system. So I feel like that at least... I can't change the system, but I can at least have this impact with this person right in front of me, who's more than just their CV, you know, more than their human bodies, they're a human person with different motivations. And can I plant one kind of philosophical seed that was a gift for me that I hope would be a gift for them and sort of bear fruit down the line?

[00:15:42] Dr. Cifu: I love the way you put that because, you know, the Bucksbaum Institute is involved with this Clinical Excellence Scholars Track which actually works with undergrads. And I think it's a very good program. And I'm actually sort of... This sounds strange, but I'm sort of excited when students go through the Track and then decide not to do medicine because I feel like this is great, you know if we can have people honestly explore what medicine is and who they are and recognize that it's not for them, that's fine. But I like hearing you talk about, you know, that medicine needs to change, you know, just evolve, it's not that it's horrible. And probably to do that, we need to attract some people who maybe don't fit perfectly now, right? To change what it is. It is, as you say, it's just very complicated to figure out how you get the right people into the field.

[00:16:34] Dr. Yoon: I mean, this is where... Probably at multiple stages, I almost quit being a doctor because I never felt like I fit, like, why do I think about stuff this way? And these days, what I appreciate that there's growing openness to saying, "Look, you can major in the humanities and still be a good doctor." You know, I mean, at least when I was going through pre-med, it seemed like, you know, to be a good doctor, you really have to do well in biology and chemistry, you know. And so that is encouraging, I think because I think that might help attract sort of the right kinds of physician leaders who can think thoughtfully about, you know, our field. But nevertheless, not to think that I'm sort of one of those, I just feel like I'm a fellow wayfarer, just wanting to do right by my patients. Do right by sort of my own sort of career and vocation. And maybe lay some sort of conceptual foundation for other educators to kind of take that and say, "Hey, there's something beneficial here that was a hard one from experience and pain and agony, that maybe we can sort of take and plan a curriculum or think about education in a different way that will benefit generations." That's not something obviously, I can control, but you sort of throw it out there kind of as a prayer.

[00:17:59] Dr. Cifu: John, thanks so much for chatting today. I'm not sure we've solved anything, but it's really super interesting stuff. So thanks for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage or on Twitter.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.