The Good Physician
Maimonides the Physician: A Model for Our Time?
Alan Astrow, MD, Maimonides Cancer Center
Medical professionalism as defined by the American Board of Internal Medicine (ABIM) argues for "the primacy of patient welfare" based upon "dedication to serving the interest of the patient." The ABIM acknowledges the necessary role of "altruism" underlying the physician's dedication, but leaves open where the physician might find a basis for this crucial internal state. The life and thought of Moshe ben Maimon, Maimonides, 1138-1204, based on recent scholarship, may offer a useful model. Born in Andalusia (modern Spain), Maimonides fled religious persecution and settled in Egypt. He became and remains one of leading Jewish thinkers of all time, author of three profound works of scholarship: Commentary on the Mishnah, Mishneh Torah, and Guide of the Perplexed. He was also one of the most prominent physicians of his era, serving as physician to the Egyptian prime minister and his court and author of at least 10 medical treatises. For Maimonides, philosophy and medical practice were connected: "The practice of medicine brings much by way of virtue, knowledge of God, and attainment of true perfection, and (medical) study and inquiry are among the greatest of works." Treatment of illness, he argued, requires that the physician understand the needs of the particular patient. Five elements of his thought retain special relevance for medical care. First, Maimonides’ religious faith was combined with thoroughgoing rationalism. He opposed magical thinking or any hint of superstitious practice and considered the use of biblical verses or religious objects for healing a form of idolatry. More fundamentally, love of God for Maimonides was rooted in appreciation of the wisdom inherent in the natural order rather than belief in miraculous interventions by the Divine. As such, he considered scientific and philosophic study to be religious obligations. Second, Maimonides believed that appreciation of the natural order, and acknowledgment of the inherent limits of all forms of human inquiry including medicine, ought to lead to awareness of the Divine attributes, “loving kindness, righteousness, and judgment," and to human actions in imitation of these. Third, while Maimonides shared the Aristotelian ethos that virtue is found in the mean between extremes, he acknowledged religious demands that we go beyond what is minimally required. He argued that as a practical matter, we best err away from the more attractive (i.e. tempting) extreme. Fourth, he demanded sensitivity toward the psychological state of those in need. "It is forbidden to rebuke a poor man or to raise one's voice in a shout at him, seeing that his heart is broken and crushed." Ill individuals were perceived as potentially isolated and vulnerable. Visiting the sick and attending to their needs were religious obligations. Avoiding the sick person was seen as akin to shedding blood. Fifth, he sought to cultivate a disposition that recognizes human limits. The universe is vast beyond our comprehension and was not created to serve humans and our desires. Familiarity with Maimonides’ works is of potential value to clinicians of all backgrounds as a way to reflect on the inner meaning of professionalism.
Go and Do Likewise: The Principle of Beneficence and the Virtue of Charity in the Practice of Medicine
Jane Abbottsmith, MPhil, Yale Divinity School
The Christian Bible upholds love for neighbor as one of the greatest commandments (cf. Mt 22:39; Mk 12:31; Lk 10:27; Jn 13:34; 1 Jn 4:21). In Luke’s famous parable of the Good Samaritan, Christians are called to respond with love to those in distress—neighbors, strangers, even outsiders and enemies. Though a simple expression of the virtue of charity, the parable gives rise to a cascade of questions about the Christian moral life. Why is it important for Christians to love neighbors? Does love for neighbor require an attitude of benevolence toward others, or actions of beneficence as well? Does it mean solicitude for the needs of the body alone, or also the spirit? Where is God in the encounter with those in distress?
For the work of medicine, a profession devoted in its very purpose to the care of the weak and the vulnerable, the parable of the Good Samaritan offers a fruitful occasion for reflection on these questions. This paper proposes to illuminate the beginnings of a moral theology of medicine, through which medical professionals may understand their care for patients as an act of service, a response to the Christian moral call to charity. The generous giving of time and talent to the wounded in need of healing; the sometimes thankless work of caring for patients in the midst of illness, depression, and conflict; the humble elevation of the needs and wishes of others above one’s own; these are occasions in which careful reflection on the principles of Christian charity might clarify what is at stake and what is experienced, spiritually, among those who care for patients.
Developing the “Good” Physician: Spirituality, Moral Intuitions, and Virtues in Medical Students
Abigail Shepherd, BA, Fuller Theological Seminary
Sarah Schnitker, PhD, Fuller Theological Seminary
Michael Leffel, PhD, Point Loma Nazarene University
Ross Oakes-Mueller, PhD, Point Loma Nazarene University
John Yoon, MD, University of Chicago Medicine
Farr Curlin, MD, Duke University
The Project on the “Good” Physician is the first national longitudinal study of moral and professional formation of American physicians over the course of medical training. The purpose of this paper is to examine the mechanisms by which spirituality influences virtue and moral formation of medical students. In particular, the influence of spirituality on moral intuitions (from Haidt’s Social Intuitionist Theory of Morality) and the virtues of generosity, mindfulness, and empathic compassion are examined.
Study participants were 563 medical students recruited by the University of Chicago (54.7 % male, 57% white). The study was conducted in three phases: initial questionnaire, follow-up and a telephone interview phase. The results for this presentation were taken from phase 2.
The follow-up questionnaire had 12 measures assessing a variety of variables such as mindfulness, empathic compassion, generosity, moral foundations for clinical decision-making, religiousness, and spirituality. It was found that the moral intuition to Care/harm was significantly correlated with the 3 virtues of mindfulness, empathic compassion and generosity (p<.001). also, there were significant relationships between spirituality and the virtues of generosity and empathic compassion (p<.001). in addition, in tests of multiple mediation models with bootstrapping, two moral intuitions (care/harm and fairness/reciprocity) partially mediated the relationship between spirituality – but not religiosity – and virtues. however, the effects of spirituality on virtues cannot be completely explained solely by moral intuitions. future directions concerning other mediating processes will be discussed as will implications of findings for medical training.
Religion, Sense of Calling and the Practice of Medicine: Findings from a National Survey of Primary Care Physicians and Psychiatrists
Jiwon Shin, MA, Irvine School of Medicine
John Yoon, MD, University of Chicago
Andy Nian, BS, Northwestern University
Farr Curlin, MD, Duke University
Objectives: A strong sense of calling is a concept with religious and theological roots. However, it is unclear whether contemporary US physicians still embrace this concept in their medical practice, particularly in the fields of primary care and psychiatry. This study assesses the association between religious characteristics and endorsing a strong sense of calling among practicing primary care physicians (PCP) and psychiatrists.
Methods: In 2009, a questionnaire was administered to a stratified random sample of 2016 US PCPs and psychiatrists. Physicians were asked whether they agreed with the statement: “For me, the practice of medicine is a calling.” Primary predictors included demographic and religious characteristics.
Results: Among eligible respondents, the response rate was 63% (896/1427) for PCPs and 64% (312/487) for psychiatrists. 40% of PCPs and 42% of psychiatrists endorsed a strong sense of calling. Physicians who were more religious or spiritual were more likely to strongly agree that medicine is a calling. Among PCPs, physicians with a religious affiliation were more likely to report a strong sense of calling (multivariate odds ratio of 3.3, 95% confidence interval [1.2-8.8] for Muslims; OR 2.4[1.3-4.5] for Catholics, and OR 4.5[2.3-8.9] for Evangelical Protestants, compared to no religious affiliation).
Conclusions: Religion and spirituality is associated with a strong sense of calling among US PCPs and psychiatrists. A sense of calling in work may be a relatively unexplored intrinsic motivating factor for physicians, and religious traditions may be offering resources and practices that cultivate a strong sense of calling during the process of medical education.
Whole Person Care and Moral Formation in Student Physicians
Grace Oei, MD, Loma Linda University
Carla Gober, PhD, MPH
Medical school education research has identified challenges in educating the student physician. One challenge is the moral and ethical development of future physicians and the effect of the educational process on ethical formation. Classes specifically relating to ethical behavior and the physician-patient relationship are required in the curriculum. Yet despite this training, literature indicates that the “hidden curriculum” a medical student encounters during his/her ward rotations, which may require the student to make a choice between deferring to a superior or advocating for the patient, has as much to do with moral and ethical development as the stated curriculum itself. All of this suggests that something of a more encompassing nature is needed.
For this reason, we would like to present a framework of medical education designed specifically to encourage moral reasoning and ethical formation based on a philosophy of wholeness and whole person care. Starting with the principle of wholeness, the medical curriculum at one institution was designed to be more accountable to its vision of educating physicians to be competent in providing whole person care, as well as in experiencing wholeness themselves. A specifically spiritual component provides the philosophical and theological basis for the understanding of both care for others and care for self.
The framework is guided by a nationally adopted competency-based curriculum. There are four sub-competencies that guide education around whole person care, wholeness, and ethical decision-making and practice. One falls within the main domain of Patient Care, the second within the domain of Medical Knowledge, and the remaining two sub-competencies fall within a uniquely developed domain entitled Whole Person Care. There are six courses and one elective designed to meet these competency requirements, resulting in one of the largest medical school curriculums specifically developed to teach wholeness, whole person care and ethical practice from a theological and spiritual perspective.
In the first year medical students learn the concept of whole person care and how to obtain a patient’s spiritual history using an institutionally developed tool. Students are then encouraged to apply their knowledge during their clinical rotations and are given feedback by preceptors trained in the concept and practice of patient wholeness. Students also learn the theological principles and theories related to whole person caregiving and how to use a whole person care model. After familiarity with this concept is established students learn the theories and principles that inform ethical health care decision-making with attention to ethical dilemmas commonly seen in clinical practice. The final component addresses personal wholeness. Medical students explore how wholeness relates to their personal moral values and are prompted to develop strategies to improve personal wholeness.
We believe the focus on wholeness and whole person care from a theological and philosophical basis in medical school will nurture empathy, stimulate moral reasoning and encourage the ethical formation necessary to equip physicians to treat the whole patient in a ever changing biomedical landscape.
Alan Astrow, MD, Maimonides Cancer Center
Medical professionalism as defined by the American Board of Internal Medicine (ABIM) argues for "the primacy of patient welfare" based upon "dedication to serving the interest of the patient." The ABIM acknowledges the necessary role of "altruism" underlying the physician's dedication, but leaves open where the physician might find a basis for this crucial internal state. The life and thought of Moshe ben Maimon, Maimonides, 1138-1204, based on recent scholarship, may offer a useful model. Born in Andalusia (modern Spain), Maimonides fled religious persecution and settled in Egypt. He became and remains one of leading Jewish thinkers of all time, author of three profound works of scholarship: Commentary on the Mishnah, Mishneh Torah, and Guide of the Perplexed. He was also one of the most prominent physicians of his era, serving as physician to the Egyptian prime minister and his court and author of at least 10 medical treatises. For Maimonides, philosophy and medical practice were connected: "The practice of medicine brings much by way of virtue, knowledge of God, and attainment of true perfection, and (medical) study and inquiry are among the greatest of works." Treatment of illness, he argued, requires that the physician understand the needs of the particular patient. Five elements of his thought retain special relevance for medical care. First, Maimonides’ religious faith was combined with thoroughgoing rationalism. He opposed magical thinking or any hint of superstitious practice and considered the use of biblical verses or religious objects for healing a form of idolatry. More fundamentally, love of God for Maimonides was rooted in appreciation of the wisdom inherent in the natural order rather than belief in miraculous interventions by the Divine. As such, he considered scientific and philosophic study to be religious obligations. Second, Maimonides believed that appreciation of the natural order, and acknowledgment of the inherent limits of all forms of human inquiry including medicine, ought to lead to awareness of the Divine attributes, “loving kindness, righteousness, and judgment," and to human actions in imitation of these. Third, while Maimonides shared the Aristotelian ethos that virtue is found in the mean between extremes, he acknowledged religious demands that we go beyond what is minimally required. He argued that as a practical matter, we best err away from the more attractive (i.e. tempting) extreme. Fourth, he demanded sensitivity toward the psychological state of those in need. "It is forbidden to rebuke a poor man or to raise one's voice in a shout at him, seeing that his heart is broken and crushed." Ill individuals were perceived as potentially isolated and vulnerable. Visiting the sick and attending to their needs were religious obligations. Avoiding the sick person was seen as akin to shedding blood. Fifth, he sought to cultivate a disposition that recognizes human limits. The universe is vast beyond our comprehension and was not created to serve humans and our desires. Familiarity with Maimonides’ works is of potential value to clinicians of all backgrounds as a way to reflect on the inner meaning of professionalism.
Go and Do Likewise: The Principle of Beneficence and the Virtue of Charity in the Practice of Medicine
Jane Abbottsmith, MPhil, Yale Divinity School
The Christian Bible upholds love for neighbor as one of the greatest commandments (cf. Mt 22:39; Mk 12:31; Lk 10:27; Jn 13:34; 1 Jn 4:21). In Luke’s famous parable of the Good Samaritan, Christians are called to respond with love to those in distress—neighbors, strangers, even outsiders and enemies. Though a simple expression of the virtue of charity, the parable gives rise to a cascade of questions about the Christian moral life. Why is it important for Christians to love neighbors? Does love for neighbor require an attitude of benevolence toward others, or actions of beneficence as well? Does it mean solicitude for the needs of the body alone, or also the spirit? Where is God in the encounter with those in distress?
For the work of medicine, a profession devoted in its very purpose to the care of the weak and the vulnerable, the parable of the Good Samaritan offers a fruitful occasion for reflection on these questions. This paper proposes to illuminate the beginnings of a moral theology of medicine, through which medical professionals may understand their care for patients as an act of service, a response to the Christian moral call to charity. The generous giving of time and talent to the wounded in need of healing; the sometimes thankless work of caring for patients in the midst of illness, depression, and conflict; the humble elevation of the needs and wishes of others above one’s own; these are occasions in which careful reflection on the principles of Christian charity might clarify what is at stake and what is experienced, spiritually, among those who care for patients.
Developing the “Good” Physician: Spirituality, Moral Intuitions, and Virtues in Medical Students
Abigail Shepherd, BA, Fuller Theological Seminary
Sarah Schnitker, PhD, Fuller Theological Seminary
Michael Leffel, PhD, Point Loma Nazarene University
Ross Oakes-Mueller, PhD, Point Loma Nazarene University
John Yoon, MD, University of Chicago Medicine
Farr Curlin, MD, Duke University
The Project on the “Good” Physician is the first national longitudinal study of moral and professional formation of American physicians over the course of medical training. The purpose of this paper is to examine the mechanisms by which spirituality influences virtue and moral formation of medical students. In particular, the influence of spirituality on moral intuitions (from Haidt’s Social Intuitionist Theory of Morality) and the virtues of generosity, mindfulness, and empathic compassion are examined.
Study participants were 563 medical students recruited by the University of Chicago (54.7 % male, 57% white). The study was conducted in three phases: initial questionnaire, follow-up and a telephone interview phase. The results for this presentation were taken from phase 2.
The follow-up questionnaire had 12 measures assessing a variety of variables such as mindfulness, empathic compassion, generosity, moral foundations for clinical decision-making, religiousness, and spirituality. It was found that the moral intuition to Care/harm was significantly correlated with the 3 virtues of mindfulness, empathic compassion and generosity (p<.001). also, there were significant relationships between spirituality and the virtues of generosity and empathic compassion (p<.001). in addition, in tests of multiple mediation models with bootstrapping, two moral intuitions (care/harm and fairness/reciprocity) partially mediated the relationship between spirituality – but not religiosity – and virtues. however, the effects of spirituality on virtues cannot be completely explained solely by moral intuitions. future directions concerning other mediating processes will be discussed as will implications of findings for medical training.
Religion, Sense of Calling and the Practice of Medicine: Findings from a National Survey of Primary Care Physicians and Psychiatrists
Jiwon Shin, MA, Irvine School of Medicine
John Yoon, MD, University of Chicago
Andy Nian, BS, Northwestern University
Farr Curlin, MD, Duke University
Objectives: A strong sense of calling is a concept with religious and theological roots. However, it is unclear whether contemporary US physicians still embrace this concept in their medical practice, particularly in the fields of primary care and psychiatry. This study assesses the association between religious characteristics and endorsing a strong sense of calling among practicing primary care physicians (PCP) and psychiatrists.
Methods: In 2009, a questionnaire was administered to a stratified random sample of 2016 US PCPs and psychiatrists. Physicians were asked whether they agreed with the statement: “For me, the practice of medicine is a calling.” Primary predictors included demographic and religious characteristics.
Results: Among eligible respondents, the response rate was 63% (896/1427) for PCPs and 64% (312/487) for psychiatrists. 40% of PCPs and 42% of psychiatrists endorsed a strong sense of calling. Physicians who were more religious or spiritual were more likely to strongly agree that medicine is a calling. Among PCPs, physicians with a religious affiliation were more likely to report a strong sense of calling (multivariate odds ratio of 3.3, 95% confidence interval [1.2-8.8] for Muslims; OR 2.4[1.3-4.5] for Catholics, and OR 4.5[2.3-8.9] for Evangelical Protestants, compared to no religious affiliation).
Conclusions: Religion and spirituality is associated with a strong sense of calling among US PCPs and psychiatrists. A sense of calling in work may be a relatively unexplored intrinsic motivating factor for physicians, and religious traditions may be offering resources and practices that cultivate a strong sense of calling during the process of medical education.
Whole Person Care and Moral Formation in Student Physicians
Grace Oei, MD, Loma Linda University
Carla Gober, PhD, MPH
Medical school education research has identified challenges in educating the student physician. One challenge is the moral and ethical development of future physicians and the effect of the educational process on ethical formation. Classes specifically relating to ethical behavior and the physician-patient relationship are required in the curriculum. Yet despite this training, literature indicates that the “hidden curriculum” a medical student encounters during his/her ward rotations, which may require the student to make a choice between deferring to a superior or advocating for the patient, has as much to do with moral and ethical development as the stated curriculum itself. All of this suggests that something of a more encompassing nature is needed.
For this reason, we would like to present a framework of medical education designed specifically to encourage moral reasoning and ethical formation based on a philosophy of wholeness and whole person care. Starting with the principle of wholeness, the medical curriculum at one institution was designed to be more accountable to its vision of educating physicians to be competent in providing whole person care, as well as in experiencing wholeness themselves. A specifically spiritual component provides the philosophical and theological basis for the understanding of both care for others and care for self.
The framework is guided by a nationally adopted competency-based curriculum. There are four sub-competencies that guide education around whole person care, wholeness, and ethical decision-making and practice. One falls within the main domain of Patient Care, the second within the domain of Medical Knowledge, and the remaining two sub-competencies fall within a uniquely developed domain entitled Whole Person Care. There are six courses and one elective designed to meet these competency requirements, resulting in one of the largest medical school curriculums specifically developed to teach wholeness, whole person care and ethical practice from a theological and spiritual perspective.
In the first year medical students learn the concept of whole person care and how to obtain a patient’s spiritual history using an institutionally developed tool. Students are then encouraged to apply their knowledge during their clinical rotations and are given feedback by preceptors trained in the concept and practice of patient wholeness. Students also learn the theological principles and theories related to whole person caregiving and how to use a whole person care model. After familiarity with this concept is established students learn the theories and principles that inform ethical health care decision-making with attention to ethical dilemmas commonly seen in clinical practice. The final component addresses personal wholeness. Medical students explore how wholeness relates to their personal moral values and are prompted to develop strategies to improve personal wholeness.
We believe the focus on wholeness and whole person care from a theological and philosophical basis in medical school will nurture empathy, stimulate moral reasoning and encourage the ethical formation necessary to equip physicians to treat the whole patient in a ever changing biomedical landscape.