Wednesday, February 19, 2014

A conversation with a medical student about the natures of health, mission, and career

By Ty

The following is an actual conversation between a medical student and me.  His comments and questions are in black.  Mine are blue.

Thanks for such a thoughtful response. I have been pondering the questions you have posed this whole weekend, and most certainly have not come to any satisfying answers.

Don't be too hard on yourself.  It took me years to start to make some sense out of these things.  But good for you for being honest about it.  The first hurdle to get over (and you already have) is realizing that you don't have all the answers, and having the humility to seek honestly.  I find that many students are really not intellectually honest--they assume that their education (id est, ideology) has all the answers, or perhaps they intuitively fear that it doesn't, so they are afraid to engage.  Actually I think your answers below are a pretty good start.  You are way ahead of where I was as a 3rd year medical student!

The blog post I first read was “A Confession.” The honesty with which you write resonated with me. Also when you talked about "the small amount of curative care" you are providing at the clinic and also struck a cord with me as well. It seemed to me you were implying there must be more work to be done, in not just providing primary care but also in teaching and change the way people thought and lived. I went on a short term medical mission trip during undergrad and remember upon coming home thinking home we helped cure people, gave them pills and such, but that they would just get sick again. What we did was good, it helped relieve suffering, but it wasn't the end all be all. And at the same time you pointed out, the answer is also not bringing Western medicine and training. Our purpose is greater still. It may be more difficult and not as popular, but it is true and I like that.

You are right about much of this.  Most students don't have the insight to realize that the small amount of curative care, while a good thing, is far from complete.  I think this is often because students usually are still pretty enamored with the technology of medicine (which is in fact impressive).  But usually this idolatry has started to change around the time of internship.  Then they become cynics (disappointed idealists), which is perhaps worse than idolatrous idealism, because it’s still idolatry, but a lower idol.  Older docs tend to more easily see the relative ineffectiveness (and even possible--nay usual--harm) of the short term curative care mission trips.  They are fine to do, but must be done very carefully and in genuine partnership with the local church—way more easily said than done.
Much, much more is possible--and necessary if we are to join Christ in building His kingdom.  Certainly He doesn't want Africa to become a Welfare Continent, or Africans to be beggars--dependent upon and beholden to Western good will and deprived of the dignity of being able to improve their own lives.  But if these next steps are not taken, that is what our missions will tend toward.

Yesterday someone asked me what specialty to choose if you want to be a missionary.  You're thinking about that too.  The last 100 years in Africa missionaries have been doers in health care in Africa--and most of those people are heroes.  But Africa has changed, and we are now in a different phase of building his kingdom.  For the next 100 years, most appropriately, medical missionaries will be educators.  That is the future and I think it's what God is doing here now.  If you are going to be a doer, then it makes sense to do FP, because you have to do a bit of everything out here.  Most of what we do is children and OB, with lots of other things thrown in.  Maybe 30% pediatrics, 30% OB, and 40% everything else.  FP training is the next wave of improvement in medical services for the next 20-40 years in Africa because it will get basic primary care to the villages.  There are many hundreds of African doctors being trained right now, and that is growing fast.  The next step will be to develop residency training for them.  First it will be FP residencies, and other primary care residencies.  There are dozens of FP residencies in Africa right now.  Within 10 years I believe there will be 100 or more.  Of course it makes sense to start teaching specialties too—soon—even now in some places.  So, within 10 years, it will be appropriate to be any specialty as long as you are willing to be a teacher primarily.  That's already what I'm doing.  I'm teaching much more than I'm doing.

So to your question of what is health? I spent a lot of time thinking about this and still am. I can see how you could spend a month simply talking through this one question. I started with health is the lack of any medical pathology.

That is in fact the party line that is taught in almost every university--either tacitly or overtly.  Any clever philosophy student, I think, would see that it is inadequate right away.  However that exact definition comes out of the mouths of people at every level of the institution, and strangely hardly goes challenged at all.  Worse yet, the subject doesn't really even come up!  We just go about our business with catheters, scalpels, and chemicals, and don't even really think about what ultimate goal we are actually aiming at.  This deficiency of big picture understanding and purpose is a major source of the cynicism mentioned above.  The cynicism, while wrong, and destructive, is hard to be judgmental of: Who doesn't get tired of admitting the same chronic (alcoholic, obese, depressed, or fill in the blank here) patient to the floor over and over again, and going through the same technological motions over and over again, knowing that they are inadequate tools for the problem and thus won't work?  You have seen the residents admit many of these cases to the floors by now--it's probably half the patients.  Do the residents act like they think that what they are doing is going to at some point start to work and eventually deliver this person to health?  They know (intuitively, even if not consciously) that it won't work.  That's why they act the way they do.  But they don't know what else to do because they have been given no cohesive philosophical foundation for what health is.  They have just been told, "Health is the absence of disease."  By “disease” they mean bio-psycho-chemical-mechanical disorder.  But you and I know there is more to a human person than that.  The cynical residents know it too.

That seemed like a good medical school answer. But that wasn't satisfying for at least two reasons. First, that would mean no one is truly healthy since we all deviate from the norm in some way. Second, physical health is not the only determinate of health; there are many more aspects that go into one's health. 

Right, as above.

Then I though maybe a functional definition of health is better. Therefore health is simply being able to do the things one wants to do (that are within reason for a normal human) without undue interference from their body or mind. But that answer was a little too relativistic for my liking.  Health would then be different for everyone and I don't know if that is true either. Maybe someone wants to just sit on the couch and watch TV all day, so having heart failure doesn't really bother them. There most be a level of objectivity to it.

Agreed, totally relativistic--like I said, you are way ahead to realize this.  This functional definition is also typically given in the university setting.  I hear this one from students all the time too.  Your example is apt.  People can't just invent for themselves what they think health is.  There is TRUTH about what is good for you and what is not.  You can't even practice science (and try to apply it to health) if you don't believe that.  What would you say to the patient who says: "Look doc, you may think your science proves that smoking is bad, but I don't believe it's bad for me."?  It doesn't work.  You have to believe that what you tell patients is true.  And furthermore, much of what you do is tell patients what they OUGHT to do--this is inherently a moral exercise and is dependent on a belief in truth.  If you don't believe in truth, how could you possible tell a patient what they OUGHT to do?  And of course patients do want us to tell them what they ought to do.  That is why there are there.  And they want it to be true.

Furthermore, if you take this definition outside of our culture, it falls apart immediately, (and in fact falls apart in many or most contexts within our culture.)  How would it work when two different people's opinions about what they "want to do" collide?  This is inevitable.  Some people think aborting babies is bad for the health.  Others try to argue that it is good.  I am sitting in a village right now, where most people would tell me that it is "healthy" and "good" to take 12 year old girls and mutilate their genitals, by force, cutting off most of the labia majora, and sometimes labia minora and/or clitoris.  They say that makes the girls better at being wives and bearing children and that you can’t get married without it.  This is a common belief with many tribes in Africa.  On what basis may I tell them that this is not true and this practice is destructive and unhealthy?  I must believe in absolute truth to do that.  I must believe that my definition of health is right and theirs is wrong.  They are wrong even though they are in the great majority here (Mob rule doesn't make anything right).  And I must be willing to tell them what they OUGHT to do based on that Truth in which I believe.  It's either that or I just accept that pinning little girls down and cutting them with an unwashed kitchen knife is healthy.

I didn't get much further than that, except to realize that how one conceives of health is shaped by everything, your worldview, experiences, etc. My idea of what a healthy life is as a Christian may be much different than a person in Europe. Whether those conceptions of health are both true and accurate is question I don't know the answer to. It seems there is some level of relativity to health, but a good dose of objectivity as well. I would love to hear your thoughts on the matter, or seeing as that might be a month's worth of discussion, your thoughts on my thinking.

Yes, Worldview is central.  And at the root of Worldview are the questions of what you believe about the transcendent.  Who is God?  Who is Man?  What does it mean to be a human person?  What is a good human person?  You can see how and why I spend a month on this stuff--and I try to do it during foundational years.

And to define career. That was also a tricky question. I've always just thought I thought about it as what I do to make money. But when I began to think about what it really meant to me, I realized it is not just money, but how I hope to gain significance in life. And when I pose the question to myself in that way, I realize the foolishness of trying to use my job or trained skill to gain significance in this life. 

Right.  Medicine is really just a tool.  Idolizing it like idolizing a wrench.  Now it's a fantastically useful tool.  But it can't give your life meaning.  Again, think of the cynical residents.  They are cynical because they are realizing this fact--usually on an unconscious, or at least unspoken level.

I am significant because I am a child of God, known by Him, and any earthly significance I seek out pales in comparison. 

Amen.  Career is not a bad thing.  But it's not a first thing.  To adapt a witticism from C.S. Lewis:  Aim at heaven (Christ, the first thing) and you will get everything else thrown in--including a career.  Aim at a career, and you will get neither.

So now I don't really know what to think, other than I probably shouldn't think of my life as being defined by my career, at least in terms of how the world views my progression as a doctor and growing in standing among my peers. My big question has always been knowing that my career is not where I will ultimately find my significance, how to I conceive of my work and how do I go about my training? To illustrate, early on during medical school I was torn about how much to study. On one hand I want to do things with excellence and honor God with my work, but I realized that "good" soon started to conflict with honoring my marriage and loving my wife. I resolved that by not pursuing the highest marks but trying to learn what I could well, but not worrying myself with being the best or trying to get AOA or whatever else awards. But I am starting to realize that conflict will always arise. How do I honor my patients and give them my best when that might conflict with my family? I don't know if you have any good answers, but just questions I have when I think about the idea of a career. 

You are right about these conflicts.  Career falls pretty far down on the list of God's priorities for us.  This is one of the reasons we need to have a biblical understanding of health as a cohesive philosophical foundation for the practice of medicine.  The Bible actually makes it quite clear that the order of priorities goes like this:
1.         God
2.         Your spouse
3.         Your kids
4.         Your calling, including, school, career, and ministry.  
5.         Earning a living; for many Americans and basically all doctors, this necessity can be subordinated to #4.

Put any of these things higher on the list than it deserves, and you will lose everything on the list that you have put under it--and you likely won't get the thing that you have wrongly over prioritized either.  Good for you that you didn't put school above your wife and in the end lose her.  I have seen that happen to way too many Christian students in medical school.  When you are 80 you are going to still want to have God, wife, and kids.  You won't care a whit for medicine or career.

How often are you in Tanzania? My original thought concerning coming to Tanzania was possibly next Spring. I have a very strong desire to be able to go with my wife, I want to learn and serve alongside her. Unfortunately her job is not very lenient with time off so we would probably need a good bit of foreknowledge if we wanted to be able to go together. 

We are here usually twice a year.  A few months in the summer and few months in the winter.  The summer is so that we can do the summer seminar I have been talking about, which is usually with about 15 students.  In the winter we take 3rd and 4th year medical students as well as residents for rotations, during which time we do this stuff too, but they also do a fair amount of clinical work in our clinic--usually because their school wants them to in order to get credit.  You will be most welcome to come next Jan-March.  Come for 2 rotations if you can!  And I applaud you for wanting to bring your wife.  We are fully supportive of that.  In fact in an hour I'm driving into town to pick up a medical student, his wife, and their 18-month-old son.  We are not just family friendly, we are family promotional.

Thank you again for your response and I look forward to continuing our conversation. Your letter was greatly refreshing to my soul and stirred things in my heart that had been left unprovoked for far too long. 

Like I said, after what you've been through, you need "a good brainwashing."  See Romans 12:1 and 1 Peter 4:1, both about our minds being transformed into the likeness of Jesus.

While I'm thinking of it, given that I’ve spent an hour or more on this, what do you think if I post the conversation above on our blog?  The reason for my request is: as you know, you are not the only person that needs to have this conversation.  Someone else out there might be blessed by it.

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