At the end, a focus on values, purpose, attention, truth

It is hard to believe that my time as ACP President is nearing its end. This month at Internal Medicine Meeting 2019 in Philadelphia, my new home professionally as well, I will pass the baton to the current President-elect, Robert M. McLean, MD, FACP. The time passes quickly. In this last column, I want to thank you for the privilege of listening to and learning from you over the past year. Thank you for your openness. In this last column, I would like to share what I have learned of your priorities and your challenges.

On values

As we've engaged in conversation, you have noted the unifying power of focusing on values. Beginning the conversation with what brings us together as physicians, as internists, allows the subsequent discussion to be grounded on shared values. From this common ground, potentially divisive conversations on specific issues can often be more open, flexible, and likely to lead to understanding. In contrast, when we start the conversation with an issue, we invite the other to take a stand, a position. The interaction is then focused on persuasion instead of on understanding and compassion.

On purpose

As we've talked, many of you have openly shared not only your successes but also your lows. Many of you noted that these challenges bring the opportunity to learn, to bounce back, and to be better. You shared that administrative burdens take a toll because of the extra time they require but also because they fill our time with activities devoid of meaning or purpose. When we feel like cogs in a wheel, when we are treated like replaceable generators of RVUs, we are disconnected from meaning and purpose.

To do our job well, to care for patients well, we need time to think, to reflect, and to connect. When time is filled with busy-ness, there is no time to reflect on our experience and to connect with our meaning and purpose. Many of you spoke of the importance of purpose to healing and well-being.

On attention

Many of you raised the importance of paying attention, of paying focused attention, whether to a patient, a student, a trainee, or a colleague. Many of you noted the gift of attention as key to the healing experience, and many of you expressed frustration that the clinical experience was now structured as obstructive to focused attention. Whether the technology or the constant interruptions or just the sheer number of the demands, all make paying attention, being present, more difficult.

Some of you talked with enthusiasm about workarounds that you've created. We often talked about our struggle to set up alternate practice structures that preserve and treasure the opportunity for being present in the healing experience.

On truth

And we've spoken about truth and science, and how we've found that both are experiencing challenge. Truth is a complex word. It has such weight, such meaning, and yet, it is not clear that we agree on what truth is. As we look back over human history, truth has been debunked more than once. The beauty of the scientific method is its openness to being wrong and its ability to democratize knowledge.

Prior to the Renaissance, truth was the property of the clergy or the mystics, who were not likely nor willing to easily part with the power conferred by their keeping of the truth. Science brings forth a process, a way to test a hypothesis, and a way by which all of us can be scientists, can cast an experiment, observe the outcome, change the variables, and come up with a conclusion based on the data.

What we come up with is somewhat dependent on agreed-upon understanding. For example, for cancer clinical trials, we find favorable and practice-changing those treatments that have a survival benefit and have fewer side effects. Those are the favorable end points that we have agreed upon within the culture of medicine.

Truth is somewhat based on perspective. We know from the philosophy of science that how we ask the question begins to define the parameters, the methodology, that will discern the answer. Like the old drawing of different people describing an elephant while blindfolded, truth is better understood from multiple perspectives.

As physicians, we have experience both with the power of the art of medicine and with the power of the science of medicine. Both are critical to patient care. Truth may be the sort of thing that is double-edged. Disparate things can be true and call upon us to keep equipoise between what may appear to be not only incongruent but also opposite. Truth is not for the faint of heart. It takes courage and strength to acknowledge the different corners where truth lives.

On endings

So, I thank you. It has been an incredible year. It has been a great honor. ACP is strengthened and enriched every day by your incredible work. As we look ahead, the College will continue to work with you to address your priorities, your identified challenges, and to advance the dialogue that will move us into the coming decade.