The Family Medicine Educational Consortium (an organization that I love being a part of!) hosts an annual “This We Believe” contest modeled off of the NPR “This We Believe” project, featuring family physicians sharing their beliefs and how those beliefs affect their work (a tremendous example on the subject of dying given by one of my mentors on death can be viewed here.) I was honored to be one of three award winners for 2013 (check out the others here!) this year and the following is an expanded version of what I presented in the plenary session at the FMEC Annual Conference on 11/3/13.
I believe that transformation requires proximity.
I believe that proximity requires vulnerability.
I believe that vulnerability requires faith & love.
When I talk to a patient or my wife or anyone else that I want to have a conversation with, we have to be engaged with one another, and usually this requires physical distance. If we’re on the phone or Skyping or FaceTiming, there must be no other distractions. If my attention is drawn elsewhere—by my pager, by my cell phone, by something moving in the periphery of my vision—we’ve lost that proximity. We can diagnose an illness over the phone, fill a prescription with a fax machine, or we can even blow someone up from another country. But we can’t take off a mole or remove their appendix—much less get to know a person for who they are—unless we get close to them.
If we can’t even really exchange ideas without practically being face-to-face, we certainly can’t change people from far away. While medical technology proliferates and invades every patient encounter that we have, family physicians in particular still have that all-important trump card that is suited for every clinical scenario imaginable: the patient-physician relationship. Technology can help our relationships. It can also kill them. The people who get money and glory as technology proliferates may tell you that technology is neutral; that’s nonsense. A scalpel isn’t neutral; it’s usually dangerous unless it’s held by the right person and pointed in the right direction.
Any technology which puts more distance between us and our patients has the potential to cause more harm; while the most obvious recent examples of this are electronic medical records I am more particularly fascinated by the automobile and the airplane as technologies that purport to bring people together but also enable them to be further apart.
It used to be a lot harder for doctors to go from one country to another—whether it was physicians coming from countries with less developed medical systems to study in more technologically advanced countries or physicians from here going there. Now a capable and brilliant doctor from anywhere in the world can leave his already under-resourced home country for a more secure position, and the capable and brilliant doctor from an over-resourced technological Mecca can pop in anywhere in the world for a week to hand out some antibiotics and then go home. I hope you can see who is the benefactor in these situations.
Similarly, it used to be that you just about had to live in the same place where you worked; now you can live, work, worship, play, and be entertained in different places without the ties of proximity to hold you down. There are, of course, advantages to this—but now the disadvantage, particularly for us doctors, is that we have the freedom to be disconnected from the everyday concerns of our patients and the local history & knowledge of the places where they live, work, worship, and play. We can discharge our duties as a physician and simply be a cog in the machine.
As Wendell Berry (a farmer and writer who has done much to advance this line of thought) once said, “A community is the mental and spiritual condition of knowing that the place is shared, and that the people who share the place define and limit the possibilities of each other’s lives. It is the knowledge that people have of each other, their concern for each other, their trust in each other, the freedom with which they come and go among themselves.” Every community has its own local history, its own assets, its own weaknesses. In every place, there are people who are fierce advocates for their neighbors who disadvantage themselves for the sake of others and there are people always looking for an opportunity to take advantage of someone else.
In my own community of Sandtown in West Baltimore—where the average life expectancy is 65 years young and the infant mortality rate is triple the national average—the needs of the community can only be appreciated by people who take the time to listen. My neighbors have been assaulted by surveys— a hazard, I guess, if you live close enough to multiple academic centers. They have had a lot of people pop in to ask a few questions and then go. They have not had a lot of people come in to mentor them, to develop leaders, to suffer with them. True compassion literally means “suffer with.” As I have piloted a mental health outreach in my neighborhood and tried to find leaders within the community to deal with the severe emotional and behavioral issues that make up the day-to-day reality of inner-city Baltimore, I have had to share in the sufferings of my neighbors, especially within my church. Yet my presence nearby gives me the ability to connect with people that I would not have otherwise.
My long-term goal is to go overseas and teach at a family medicine residency in an under-resourced country. I want to give physicians in these places the opportunity to become leaders among their own people without ever leaving and reverse the trends that suck the local resources away. While there are a lot of excellent medical education opportunities that are short-term in nature that use technology to its absolute highest benefit, anyone involved a residency can attest that if I want to really see residents flourish, I’m going to have to live there. One such residency in Afghanistan has seen a lot of turmoil, but it is through those experiences that the physicians are bonded to their community.
If we want to see change in a community, we have to be there. Physically. And if not physically, then our hearts and minds and eyes and hands and our pain must be there. This brings up vulnerability. Proximity requires vulnerability. You have to expose yourself to the risk of being hurt—something that everyone who has ever invested in a patient-physician relationship knows.
I think it is certainly possible to do a lot of good at a distance. I think that good boundaries are essential, as we must carefully search where vulnerability is indicated. Like the scalpel, it can destroy a patient and their community or save them. Yet when I look at—for example—the School of Public Health at a very well-recognized university in my city and the neighborhood just a block away and the hundred years of history that have transpired between them, I have to suppose that we have drawn our boundaries a little too far.
Vulnerability requires faith & love. There is on one hand, the faith that every now and then, your suffering will be obviously worth it and your sacrifice will yield fruit; when we see patients that we stayed up late for or argued with their insurance companies on behalf of that are living healthier we can rejoice. And I do think that is an enormous benefit. Yet we also must know that such a scenario won’t always play out, indeed, we could end up more hurt than ever before.
C.S. Lewis once said, ““There is no safe investment. To love at all is to be vulnerable. Love anything, and your heart will certainly be wrung and possibly be broken. If you want to make sure of keeping it intact, you must give your heart to no one […] The only place outside Heaven where you can be perfectly safe from all the dangers and perturbations of love is Hell.”
I’m sure that using the word “love” regarding a patient-physician relationship may raise a few eyebrows. However, even the most detached and cautious doctor has felt love towards a patient—not love as a mere emotional sentiment, but as a guiding commitment to care for someone appropriately regardless of the cost.
I take care of a lot of people who make bad decisions. Many of them involve the greatest proximity you can have with another person. Many times that decision makes another person. Many times I wonder to myself as I’m talking to someone, “why on earth would you give such a sacred part of yourself to this idiot who doesn’t even have the decency to hold your hand while you’re giving birth?” I am terrified by the number of people who are like this.
I was born at the hospital that I work at. My parents were those people, broken people from broken families. They had no idea what they were doing when I was born. They were loved abundantly by others who gave and gave, which in time transformed them into parents who could love me. But that knowledge—that very, very local and proximal knowledge—always teaches me that I could very well be the second generation sitting in my office, having just brazenly impregnated a woman without any regard for her well-being. That component of vulnerability—the humility to admit that the love I have received has changed me and put me on the doctors’ stool and not on the examining table—is difficult and a fine line must be walked when cultivating relationships with patients. But it can be done.
How? I can only tell you my answer. You’ll have to figure out your own. For me, I am inspired by meditating on the fact that “The Word became flesh and dwelt among us.” Jesus became flesh and moved into the neighborhood. He suffered on our behalf—because of his enormous love—to transform our human community. His death & resurrection sealed the promise of victory over death and suffering. His righteous life was not just an example for us of how incarnation leads to transformation– it was righteousness lived on our behalf that we inhabit as we trust in Him for the forgiveness of our sins. Martin Luther King Jr. said that “The arc of the moral universe is long, but it bends towards justice.” We can know that’s true because Jesus did it first.
What we do as a community is imitate that willingness to suffer on the behalf of others and receive the transforming work of the Holy Spirit that helps us learn to suffer well. When we find our vulnerabilities, weaknesses, sins, and suffering that we experience, we take them to Him. Even when we fail our patients or our patients fail us, we’re guarded from cynicism and despair because we know that we’re just on the near side of the arc of history– and we’re still getting closer to victory. My tiny little part in that victory is helping people in my neighborhood find mental health care and teaching residents overseas.
This we believe.