Revitalising Professionalism

[Written over on the other site, but thought people might be interested]

Seggie J. Revitalising professionalism. S. Afr. Med. J. 2011 Aug.;101(8):508–509. PMID 21920118

This is yet another cracker from R&R in the Fast Lane via Sa’ad Lahri. There’s not a chance I would have found this paper otherwise so go check it out.

It’s a short, narrative review of some of the debate surrounding the nature of medical education and in particular the idea and definition of what it means for medicine to be a profession.

Some nice quotes:

professionalism is ‘a set of values, behaviours, and relationships that underpin the trust the public has in doctors’

learning of professional behaviour and absorption of professional values depends on strong, engaged relationships with positive role models

there should exist a moral contract between the medical profession and society

I want to talk a little bit more about the last one, about what the “moral contract” bit might mean.

I read a lot of a chap called Hauerwas and he describes medicine as drawing it’s moral authority from a society that refuses to abandon others who need help. Our society dedicates large amounts of money and some of its finest people to care for the ill – this in itself is a profound moral statement. Now I know that there are sound societal, economic reasons for doing health care but I really don’t think that’s why groups of humans do it.

The fact that medicine rarely cures many of the diseases that we attend to makes it even more morally significant.

For us to remain a profession (as opposed to being technicians) we must not neglect the moral aspect of what we do.

Here’s a Hauerwas quote for you to ponder.

Medicine is a profession determined by the moral commitment to care for the ill… The ability to sustain such care in the face of suffering and death is no easy enterprise, for the constant temptation is to try to eliminate suffering through the agency of medicine rather than let medicine be the way that we care for each other in our suffering… Indeed I suspect the increasing technological character of medicine with the correlative growth in specialisation reflects the attempt to substitue scientific expertise for the moral commitment necessary to maintain medicine as a coherent profession.

Suffering Presence 

Notre Dame Press: 1986; P17

Before anyone gets too upset, a moral commitment to care for the ill in no way prohibits technology or scientific expertise or so many of the things that I think really matter about emergency medicine, but in a rather twee and inadequate aphorism we need to be willing and open to care before we can cure.

 

UPDATE: Domhnall has written on something similar before so go read it too.

Volf on Embrace

in the presence of the divine trinity, we need to strip down the drab grey of our own self-enclosed selves and cultures and embrace others so that their bright colours, painted on our very selves, will begin to shine.

P60

Volf, J. M. G., & Volf, M. (1997). A Spacious Heart Essays on identity and belongingHarrisburg: Trinity Press International.

A little more Vonnegut

Back in 1931… the Great Depression was going on, so that the station and the streets teemed with homeless people, just as they do today. The newspapers were full of worker layoffs and farm foreclosures and bank failures, just as they are today. All that has changed, in my opinion, is that, thanks to television we can now hide a Great Depression. We may even be hiding a third world war.

Kurt Vonnegut

Bluebeard p82

1989

 

A little Vonnegut

“the human condition can be summer up in just one word: embarrassment.”

Kurt Vonnegut
Bluebeard
Paladin 1989
P23

Theologians of the slums

This blog has somewhat morphed into a way for me to vent and explore the stuff I’m studying. Perhaps it always was it’s just now I find it much more useful!

Found this from Marcella Athaus-Reid in a piece criticising liberation theology for being insufficient.

Unless we have theologians from the slums (not just living there as part of a church project) the liberationist argument of theological representatives contradicts itself.

Althaus-Reid M. Another Possible World. London: SCM Press; 2007. p37

This is a big question as it seems that the voice of a rich, white prod is irrelevant to the conversation. My very existence is complicit in the systems that keep people oppressed.

But it also outlines another problem – what do theologians of the slums look like? Indeed how can they do theology, when it is required that you not only read and write but are highly educated and do work in the context of the academy. It seems, in order to be a theologian of the slums, you must leave the slums and become as middle class as the rest of this.

The whole thing seems a bit irresolvable as it stands.

Any thoughts welcome.

On yet another interesting essay title

So this unit is radical hermeutics. Which I’m slowly beginning to get my head round. And this our essay title:

Choose an example of marginalization and/or exclusion from your contemporary world. How can radical hermeneutics help and/or hinder your interpretation of that example?

Any tips of good things to read on this are appreciated!

The current essay title

How might works of imaginative fiction function either as ‘texts of’ or ‘texts for’ Christian theology? Discuss, making particular reference in your answer to the doctrine of sin and William Golding’s novel The Lord of the Flies.

This is fascinating stuff. Though, as always there’s far too much to read and never enough time

On the first essay

I’ve just submitted my first essay for the theology course I’m doing. I’ve never written anything like it before so I haven’t much of a clue what to expect.

The question we were given “outline an acceptable notion of sacrifice in the old testament and the contemporary world”

Which the more I think about, the more I realise how much there is to be written about it. Problem was (as I see it), most of the reading we were given was on the Aqedah (the binding of Isaac) in Genesis 22. While it does indeed concern the potential sacrifice of a son, in reality, the sacrifice does not actually happen. Indeed the New Testament doesn’t seem to read it as a story about the nature of sacrifice but more as one of obedience.

There are all kinds of takes on the Aqedah. From Boehm, who thought that Abraham gives us a model of holy and defining disobedience in Gen 22, to Gunn, who sees Abraham as the arch-bastard patriarch whose character is revealed as wholly lacking in his willingness to sacrifice his son.

After all the reading, I came to the conclusion that there’s nothing much “acceptable” about sacrifice and Gen 22.

That being said there might be a whole lot that could be said about the Hebrew people’s understanding of sacrifice when you see it in the light and context of something like Leviticus.

In terms of the contemporary world, we have lots of acceptable sacrifice; as long as it’s

a) voluntary/autonomous and basically self-sacrificing

b) for the appropriate cause – war is still top of the list here I suspect. We can accept those who sacrifice their own lives in the pursuit of peace/justice etc…

One of the (many) problems with the essay I just submitted is that I talked a lot about Gen 22 and how it wasn’t really about an acceptable notion of sacrifice and neglected the more fruitful leviticus and modern stuff. My excuse will be that none of the reading covered that but we’ll see…

For those really interested I’ve included my bibliography below:

Barth, Karl. Church Dogmatics III.3. Peabody: Hendrickson Publishers, 2010.

Boehm, Omri. 2007. The binding of Isaac: a religious model of disobedience. London: T&T Clark.

Douglas, Mary. Purity and danger: an analysis of concept of pollution and taboo. London: Psychology Press, 2002.

Fewell, Danna Nolan, and David M Gunn. “Tipping the Balance: Sternberg’s Reader and the Rape of Dinah.” Journal of Biblical Literature 110, No. 2 (1991): 193–211.

Girard, René. Violence and the sacred. Baltimore: The Johns Hopkins University Press, 1986.

Gunn, David M, and Danna Nolan Fewell. Narrative in the Hebrew Bible. Oxford: Oxford University Press, 1993.

Kierkegaard, Søren. Fear and Trembling. London: Penguin Classics, 2005.

Klawans, Jonathan. Purity, sacrifice, and the temple: symbolism and supersessionism in the study of ancient Judaism. Oxford: Oxford University Press, 2005, http://www.oxfordscholarship.com/.

LaCocque, Andre. “About the ‘Aqedah’ in Genesis 22: A Response to Laurence A. Kant.” Lexington Theological Quarterly 40 (2005): 191–201.

Moberly, R W L. The theology of the book of Genesis. New York: Cambridge University Press, 2009.

Sternberg, Meir. “Biblical Poetics and Sexual Politics: From Reading to Counterreading.” Journal of Biblical Literature 111, No. 3 (1992): 463–488.

Taylor, Charles. A secular age. Cambridge: Belknap Press.

Von Rad, Gerhard. Genesis – a Commentary. Trans. John H Marks  London: S.C.M. Press, 1972.

Westermann, Claus. 1985. Genesis 12-36: a commentary. Trans. John Scullion London: SPCK, 2007.

Yang, Andrew S. “Abraham and Isaac, Child Abuse and Martin Luther.” Lutheran Quarterly 19 (2005): 153–166.

The second commandment

For my theologising I have to read a chap called Patrick Miller

On the second command, and the tendency for us to make theological graven images, he says this:

theology is a very dangerous game and always teeters on the brink of idolatry, with the tendency, intentional or not, of seeking to get at God for our own well-being and program

P58

Miller, Patrick D. 2009. The Lord Alone. The Ten Commandments. Westminster John Knox Press

Something remembered from Paul Ramsey

I read this book called “Patient as Person” quite a few months back and I’d jotted this down and forgotten about it.

When talking about euthanasia and aggressive, intensive medical care in the face of a terminal prognosis, Ramsey suggest that these two, quite dissimilar things are really expressing the same thing. They are both expressing a denial of death.

To pursue aggressive medical means till the body is decaying is to deny that part of our human existence its end.

And to choose and actively pursue death either at the individuals choice or via a surrogate is an attempt to escape the death before us.

Barth on the word of God

I’m attempting to do a volume a year of the dogmatics. So i’ll be 44 when I finish. Though it’s already August and i’m only a quarter way through the first.

Though I did find this where Barth talks about the nature of the word of God:

in the prophets and the apostles the church has a concrete counterpart by which it is reminded of god’s past revelation, set in expectation of future revelation, and thus summoned to proclamation and empowered for it

When I start studying in September it seems I have the pleasure of a lecture from NT Wright on the five act play as a hermeneutical model which I think addresses the same issue of the nature of the word of god.

The God we disbelieve in

This is one of the most useful things I’ve learnt in the past 4 or 5 years. I remember chatting with a really thoughtful doc that I worked with in NZ and it came to me that I didn’t believe in the God that he didn’t believe in either.

I’ve had that confirmed to me lots of times since but in reading through McGrath’s textbook on theology I found this in a section on the trinity

The God in whom the nineteenth and twentieth centuries came to disbelieve had been invented only in the seventeenth century

He is of course quoting Alasdair Macintyre.

Holidays # 3

While still in Kerry we went to the Skelligs. Largely on the inspiration of Patrick Mitchel. And when he said it was fine to have his small children on it then I thought it must be a walk in the park. So i blame him. Just to be clear.

The skelligs are here

From the mightly Wikipedia

Skellig Michael (from Sceilig Mhichíl in the Irish language, meaning Michael’s rock), also known as Great Skellig, is a steep rocky island in the Atlantic Ocean about 9 miles (14.5 kilometres) from the coast of County Kerry, Ireland. It is the larger of the two Skellig Islands.

After probably being founded in the 7th century, for 600 years the island was a centre of monastic life for Irish Christian monks. The Gaelic monastery, which is situated almost at the summit of the 230-metre-high rock became a UNESCO World Heritage Site in 1996. It is one of Europe’s better known but least accessible monasteries.

Let me just say that the boat ride out was the only really terrifying moment. I don’t even think we got a bad day but I was thrown out of my seat onto the floor on one occasiona and there was a fair amount of vomiting and tears and screaming involved.

That said…

The place is stunning.

There’s a main site that you can get to fairly easily. Apparently there was a hermitage; a separate site on the NE of the island. If the remoteness wasn’t remote enough for you.

Puffins always struck me as very sad looking birds. Like they’re always on the verge of tears or something. Anyhow this one turned round and tried to poo on me right after this photo. Bloody birds…

The island on the right is little Skellig. The person on the left standing nervouslyvery near the solid bit of the path is my wife.

It is a remarkably pointy, tilted pieve of rock. It’s not my poor photographic skills. it’s just the way it is.

Lots of fun. As long as you don’t look down.

Holidays # 2

We had a week in Kerry, staying in this lovely wee house:

It has a little river running past it just to the right of the Volvo. One day at high tide I had a very chilly swim in it.

There were of course lovely beaches, even if they were a tad inaccessible.

The beach even had this odd ship shaped house with a bizarre little river of sinking sand that tried to swallow our party every time we tried to cross it.

We climbed the tallest peak in Ireland

and I forgot from the previous two times I climbed it how terrifyingly “ridgey” it is on the circle route to get down

And despite Lorraine’s boots making her feet hurt so bad that she considered divorcing me for my route planning, we got down just fine.

On a different note:

I did this. Not some thief. Me. Sigh… The Volvo is now more duct tape than machine…

 

 

Holidays # 1

My whole life is holiday, yadda, yadda, yadda…

Anyhow.

I’ve got to do some fun stuff this summer so here it is.

We found this on Portstewart strand. Any ideas?

I did notice some extreme cruelty to animals as evidenced here:

And we got a lovely walk here too.

Bioethics in medical education

[I wrote this for my medical blog as a practice of saying something coherent about the idea of virtue ethics in medical training. This is one of the reasons I got interested in doing the theology masters. It should be fairly readable to non-medics. Let me know what you think]

Ethics is tricksy.

No way round it.

There are lots of reasons for that, the type of thing that keeps philosophy and ethics departments in good work.

Approaches to ethics in med school are always going to be hopelessly inadequate, it’s perhaps unfair to expect much else.

This paper discusses ethics and how to train people in ethics in EM. And they say lots of good things. It’s just that it’s a tad reductionist for my liking.

Ethics curriculum for emergency medicine graduate medical education. J Emerg Med. 2011 May;40(5):550-6. Epub 2010 Oct 2. PMID 20888722

Fig 1 from the paper

That figure may make a lot of sense to you. It certainly makes sense to me I’m just not sure it’s an entirely appropriate way to teach ethics or indeed practice it.

Or maybe it is. It’s probably a perfectly decent way to teach ethics if you believe that ethics is just another abstracted category to be put alongside physiology and anatomy.

The authors make this quote

a sound understanding of the principles of bioethics is necessary to become a compassionate and effective physician

Here I disagree. I do not know how an understanding of bioethics makes a doctor more or less compassionate.

Compassion in the context of virtue, character and humanity may be a learnable skill through the practice of a life lived but I’m not sure it’s teachable in the sense you can pass an MCQ at the end of it.

They do mention one thing that might be good material for fruitful reflection

Ethics education can be effectively provided, not only through behaviour modelling in the clinical environment, but also in formal didactic instruction

While I think the didactic instruction has its limitations as discussed above I think the “behaviour modelling” is fascinating.

Which brings me to this paper:

A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Ann Emerg Med. 2011 May 28. [Epub ahead of print] PMID 21624702

Medicine is a lot like apprenticeship. In the sense that personalities and relationships are a key part of our learning and skill development. I model the behaviour and knowledge and skills that I find in my seniors.

These guys called the modelled professionalism by seniors “the hidden curriculum” which is kind of a neat name. Basically the students take on the habits of the senors and the practices observed.

I am deeply grateful to the people I have worked with both for the things that they have taught me to do and the things that I have seen them do and vowed never to repeat!

The term “holistic” is in vogue when it comes to talking about patients. It’s unfortunate that it’s become a buzzword as it’s actually a useful reminder that we treat people, not just patients, and certainly not conditions.

To think of ethics training and the practice of medicine as easily definable and teachable components that can be formed in an algorithm is something I find quite inadequate.

Some (tongue in cheek) conflicts of interest:

• I think medical training is there to produce people capable of caring for the suffering, sick and the dying. These people need to both retain their own humanity and help their patients retain theirs. (This need not be in conflict with the good science and practices that fill medical research journals)
• As background to this I am not a materialistic determinist. I have problems with a lot of the assumptions modernity has given us. I am a confessing Christian and a big fan of virute ethics. Though I’ll gladly admit Aristotle was a bit bonkers on a whole range of things…
• I’m starting a masters in theology in the hope of exploring this kind of thing a bit further. And hopefully make it in some way intelligible and not just vague allusions to Macintyre…

Harvest is here… well not quite…

Off on hols to kerry for a bit. Decided to pull a few veg to bring with us for food

However when I add a scale they’re not quite as impressive

There’s some tasty eating in a carrot the size of a euro…

Clues as to why my brownies kick your brownies ass

Though it makes me suspect they’re not suitable for small children or if you have to operate heavy machinery…

 

 

 

 

 

Kindness

On the few occasions that I stop long enough to consider even hearing the still small voice of God, I think of kindness.

In the sense of kindness, gentleness, self-control  that is. Fruits of the spirit and all that.

I once quoted Vonnegut from one of his novels where the character Eliot Rosewater is baptising/christening and gives his one rule for living on planet earth

God damn it you’ve gotta be kind…

I find myself deeply moved by kindness. Kindness observed amongst those I know and don’t know. The kindness of the people I work with in how they deal with people. And I lament my failings in dealing with those I love; how quick I am to anger or criticism or jibes – more in the name of humour and superiority than grace.

I get angry at the lack of kindness, most often exhibited on occasions where I work in the hospital. The “God damn it..” in exasperation and anger seems fitting.

Hippocrates shadow

I’ve just finished reading this (in a rather frenzied 8 hour marathon) fascinating book by David Newman, a damn fine educator and researcher in emergency medicine

It covers all the problems with medicine that i’ve been torturing my poor friends over for donkeys now.

There’s lots of great stuff in it but I think my personal favourite is chapter 4 on communication with patients.

Lack of communication begets lack of communication. a downward spiral closely ties to medicine’s movement away from contact toward technology, a movement embraced by patients and doctors alike. Both groups crave the safety and the seemingly unimpeachable science represented by blood tests, x-rays, and pills

If you’re fed up with me ranting to you about the problems inherent in the medical world then read this. It’s much better articulated than I’ll ever manage to be.

It’s written for a lay audience so it’s fairly accessible to everyone