By: Robert Englander, MD, MPH
Today’s topic is perhaps not typical for a health professions education blog – the topic of love. I will approach the topic from the perspective of a physician, because that is the one I bring, but I hope much of this discussion will apply to other health professionals.
For some background on how I got to this topic: I have devoted the scholarly part of my career to understanding and advancing Competency-based Education for the health professions (CBHPE). I am happy to say that over the past half-century or so, we have moved beyond the structure/process educational model that placed most of its focus on teaching and assessing medical knowledge and patient care. As we have focused on the outcomes necessary for physicians to meet the public’s needs, we have extended our notion of the 21st century physician to include interpersonal and communication skills, continuous improvement, professionalism and inter-professionalism, and systems thinking. Now I appreciate that these domains move the conversation forward enormously compared to the late 20th century. But even though I am certain that health care will vastly improve if we can dedicate ourselves to ensuring physicians demonstrate these competencies across the educational continuum, something still leaves me wanting when I talk about the competency domains and their requisite competencies.
The first reason relates to what brought most of us to the profession. When physicians reflect on their career drivers, they predominantly cite their desire to bring meaning to their careers through healing and caring relationships. They recognize the critical importance of science and discovery, but, for most, the scientific foundations are a means to an end and not the end itself. The end is much more related to the human aspects – healing, relationships, and caring.
The second reason that I am sometimes left wanting when working with the competencies can best be understood through a brief story from nearly 20 years ago – an “aha” moment for me. I was attending a retreat with a wonderful learning community of health professions educators devoted to catalyzing improvement in health care through education. We were engaged in a paired exercise where we had to describe a successful program we led. Then, the active listener probed for the root cause of the success. When pressing the pathology residency program director I was paired with about the “why” behind his program’s improvement, he said, “Love, Bob. It all starts with love”.
I tried to untangle what he really meant at the heart of that statement, and I think it was this: A great program has to start from a place of love: loving what he was doing; loving the residents; loving being a part of their growth; and loving the patients who would be on the receiving end of that growth. Love was, at least to my colleague, the most important foundational ingredient for success.
Love is a difficult word in the English language. The single word expresses a spectrum of definitions. The Greek language presents us with four types of love:1 1) Filial love, from the Greek philia, represents the close love of friendship; 2) eros represents physical, sensual love, 3) Storge represents familial love; and, finally, 4) agape represents unconditional, selfless, and sacrificial love. For the purposes of this blog, I am using the concept of agape, perhaps closest to the English term loving-kindness.
In reflecting on my career, I realized how much “starting with love” moved me. It was those mentors who showed loving-kindness to our patients that created indelible memories. Whether my internal medicine attending in medical school who held the hand of our brilliant schizophrenic patient with pneumonia and lice throughout my presentation the day of her admission, or a colleague comforting a sobbing mom whose child had been abused by her boyfriend, these are the seared memories for me. The physicians who loved their patients and did not judge.
I want to say up front that while I have just provided two brief stories about the doctors whose loving-kindness powerfully impacted me, I am not from the anecdotal school of medicine. The power of the story is potent, but I remain an empiricist and want to note that there is ample evidence that healing is a combination of our ever increasing prowess in diagnosis and treatment AND the many human factors that strongly affect our biology. Studies show clearly that patients whose physicians demonstrate higher empathy have better outcomes.2-3 Other studies have shown that compassion and loving relationships have a positive effect on healing.4
Now, having outlined the competencies of the 21st century physician and delineated the potential impact of loving-kindness as the reason why these competencies sometimes leave me wanting, it begs the question: “Is loving-kindness a requisite competency for a physician?” You might be surprised to hear that my answer is “no”, but I don’t think lovingkindness is a competency. Competencies are requisite abilities of physicians that can and must be taught and measured. I don’t see loving-kindness that way. A common refrain is that “not all that can be measured is meaningful and not all that is meaningful is measurable.” This is an instance of the latter. I see loving-kindness as an aspirational core attribute, central to who we seek to be as humans, both in and outside of our work. Loving-kindness is for me a continuous challenge that requires explicit reflection and action, course corrections, and an openness to strive for an ideal even knowing how elusive that ideal may be. So…I hope that the readers of this blog will all aspire to loving-kindness, especially in these trying times where judgment and “othering” are so prevalent and malignant and when so much “love” is conditional on loyalty. For physicians, we can start with the white coats you wear daily. Each time you don your white coat, starting today, I hope you will think of it as the coat of loving-kindness. Imagine a world where all of us had the requisite competencies to provide safe and effective care AND where the last thought before we entered an examination room or hospital room to meet a patient was to remind ourselves of our aspiration to lovingkindness-unjudging, unconditional love? That’s the world I want to strive for…
Refrences:
- Lewis, C. S. (1960). The four loves. Harcourt, Brace.
- Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. S. (2011). Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine, 86(3), 359–364.
- Nembhard, I. M., David, G., Ezzeddine, I., Betts, D., & Radin, J. (2023). A systematic review of research on empathy in health care. Health Services Research, 58(2), 250–263. https://doi.org/10.1111/1475-6773.14016
- Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: A meta-analytic review. PLOS Medicine, 7(7), e1000316. https://doi.org/10.1371/journal.pmed.10003164
About the Author:
Robert Englander, MD, MPH, is a Visiting Clinical Professor in the Department of Medical Education at the University of Illinois College of Medicine. Bob has spent his career focused on two areas: 1) pediatric acute care as a pediatric intensive care physician and then a hospitalist and 2) improving health professions education. His career has spanned four decades and he had a variety of leadership positions in both in-patient pediatric care and in education across the continuum at 5 universities. Bob’s scholarly focus has been on Competency-based health professions education. He co-led the development of the Core EPAs for Entering Residency and the Education in Pediatrics Across the Continuum (EPAC) pilot supported by the AAMC. He then spent 6+ years at the University of Minnesota as the Associate Dean for Medical Education where, along with an amazing team, he implemented a competency-based framework for curriculum and assessment. In 2023, Bob moved to join his partner in Chicago, Illinois, and was delighted to join the University of Illinois College of Medicine Department of Medical Education to help facilitate strategic planning.
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