William Cayley: Christmas thoughts

bill_cayley_2The Christmas holidays annually are a time for jolliness, cheer, and fun—from “Ugly Sweater” events to “White Elephant” gifts, and even The BMJ Christmas issue. It’s all in good fun, it can be especially helpful at this (often grey and gloomy) time of year, and it all seems to somehow make sense when one thinks of Christmas originating with a message of “peace and goodwill.”

Yet none of us need reminders that the daily news is filled with news of people sorely in need of peace and longing for goodwill. Refugees continue to flee persecution, insecurity, and death (and, sadly, are sometimes met with more of the same). Populist nativism is on the rise. Bombings and shootings (and threats of more) keep us on edge. Medicine itself is fraught with tensions over work hours, job performance expectations, and even patient care (I received a note this week about a system to monitor my patients’ “compliance” with health maintenance—so much for shared decision making!). And if that wasn’t bad enough, we’ve been bombarded this year with story after story of both academic misconduct and avaricious business practices, pulled off in the name of medicine.

When in training, I never understood the stories of those more senior doctors who wondered “was it worth it.” My idealism could not comprehend being overwhelmed with patient volume or administrative minutiae to the point that I doubted medicine as a career. Well, 20 years can make a difference. I still don’t doubt my calling into medicine, but sometimes it seems the challenges to my idealism come not just daily, but hourly. Being a high volume, competent, sensitive manager of problems and databases, as well as a “paid friend,” seems a daunting task.

With those thoughts in mind (they’re on my mind daily!), I was intrigued and inspired to see a “retweet” of a Christmas essay by Richard Smith from 1999, in which he writes:

Improving care for marginalised groups will thus need much more than exhortation from the pulpit or a journal—because most people are unwilling to take on the extra difficulties of caring for these people when, far from bringing professional or monetary reward, it brings the reverse . . . Medicine may somehow need to rediscover its religious underpinning while operating in an increasingly secular world. Otherwise, it’s hard to see that anything will be different in 10 years’ time.

I’m not sure that we are any better at caring for the marginalized now than we were, those 16 years ago, and I think the case he makes for recovery of religious underpinnings is even more compelling.

Certainly, there is much “bad news” that happens at least under a religious label. However, at a very simple level, the sheer number of medical establishments whose names denote a religious heritage testify to the place of the faithful in working to develop places of care, healing, and comfort.

Going further, the commitments that we physicians make when taking an oath at entry into the medical profession are not simply a statement of intent to provide competent care, rather taking a professional medical oath also involves at least some degree of commitment to a set of ideals, principles, or aspirations that include altruistic and ethical ideals. In other words, professing a medical oath is itself a quasi-religious act.

Despite all the commercial, legal, and administrative complexities that abound more and more in medical work, the fundamental commitment to care for another with healing expertise calls for something more. Indeed, perhaps the “something more” that is called for is fidelity to the commitment to care with healing expertise, even in the face of commercial, legal, and administrative distractions!

Religious traditions have statements of faith. We have no such thing in medicine, and indeed we use a plurality of professional oaths for our learners when they graduate training and enter the profession. However, one set of principles to which all of us in medicine should be able to give assent is the World Medical Association code of ethics, which states (among other things) that:

A physician shall . . . be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.

It seems we should not need reminders about this, but the daily challenges we face in medical practice tell us that we do.

Christmas is portrayed as a time of happiness and good cheer, but for those of us in medicine it should also be a time to remember ever more clearly our fundamental commitment to those who are experiencing neither peace, nor goodwill, nor cheer. It is a time to remember more clearly our commitment to the ill and needy, and especially the ill and needy among the marginalized.

That is a tall order even on the best of days, and for most of us it will sooner or later call for more than just our routine, daily business as usual, but rising to that challenge may be a central part of what it is to truly practice medicine:

Anyone who proposes to do good must not expect people to roll stones out of his way, but must accept his lot calmly if they even roll a few more upon it. A strength which becomes clearer and stronger through its experience of such obstacles is the only strength that can conquer them.

Albert Schweitzer, The Spiritual Life

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.