Hard Lessons for the Medical Frontlines

Someday, all the trenchant metaphors and pithy aphorisms you provide your students will come true. If you excel at your craft, this secret is your reward for a job well done, paradoxically troubling as it turns out to be. To those of us tasked with educating future medical professionals, the proof of this observation weighs freshly in mind. For us, the COVID-19 pandemic provided ample occasions to observe its veracity. 

Of these sayings, one particular breed took center stage during this plague year just concluded. If 2020 needed a motto, an easy frontrunner for the job would be the tried and true “when the rubber meets the road.” If asked for a practical example of what “out of the frying pan, into the fire” meant, a curt response of “2020” would more than suffice. Even the venerable “trial by fire” took on new connotations as we sent eager students into this worldwide emergency as doctors, nurses, and allied health professionals.

Such sayings seem to highlight the incommensurate relationship between knowledge learned in books and wisdom won experientially. This past year, their stark reality was revealed in ways more blunt than any professor could imagine. As educators of these healthcare professionals sent forth in such trying times, it is only fair that we who taught them apply the same scrutiny to ourselves. To answer this question is a task too large for a decade’s worth of research, let alone a single essay. However, we owe it to the trials faced by our students to submit ourselves to similar scrutiny.

What Medical Educators Owe Students (and Their Future Patients) in Light of the Pandemic

For Christian medical educators, such willing self-examination is doubly necessary. On one hand, the long-standing tradition of confession and repentance—so essential to Christian practice—should apply not only to our personal lives, but our professional ones as well. On the other, our insistence to imitate Jesus Christ, the Divine Physician, in his healing ministry demands we attend to this task. To commence this professional examination of conscience, we must ask what it was in the first place we hoped to form within our students.

In the simplest terms, our goal must be to form students who see each future patient as bearing the Image of God. They are more than mere bags of bone and blood, more than a problem to be solved. Our ministry is not one of fixing fragmented bodies, but of healing whole persons, body and soul. In the medical setting, our goal must be to equip our students to resist the manifold temptations to regard only part of our human reality.

By no means is this temptation the province of medicine alone; the instincts of the wider culture attest otherwise. Nonetheless, a predisposition within medical practice exists for falling into this frame of mind. This does not stem from a weakness in medicine, but instead proceeds precisely from its power, its overwhelming capacity to accomplish its goals, and makes such a truncated view of patients easy to adopt.

Medical practice and education are thus inclined to “miss the forest for the trees.” The trappings of the fragmented view of persons work wonders, and employing such a trees-for-the forest approach produces results a birds-eye-view of patients seemingly cannot match. Nearly peerless among other university departments, to teach medicine is to teach in the shadow of its own success. All diagnosis of the ailment afflicting medical education must begin with this fact.

Newman’s Surprising “Last Word” on Education and Medicine’s Place in the Circle of Knowledge

To this end, we turn to engaging the work of John Henry Newman, particularly his magnum opus on Catholic education, The Idea of a University. Comprised of the lectures Newman was asked to deliver as a prelude to launching the Catholic University of Ireland, today it remains singular in its vision for liberal arts education. While it may seem a strange place to begin, the fruit of such an engagement will become apparent.

It is intriguing that in a work devoted to the goal of university education as a whole, Newman chose to address medical faculty for his seeming “last word” in Part 2, Discourse 10. This decision—whatever Newman’s intention at the time may have been—has proven itself to be prophetic, given the ailment afflicting medical education outlined above. Indeed, his attention to the technological power of the medical arts proves even more pertinent now than when he first delivered the address.

To clarify, neither this essay nor Newman’s address put forth a declination narrative. Medicine is no great corrupter of a prior Eden-like existence for the liberal arts within the university. Instead, both imply a question: How shall we situate medical education within the university? An unparalleled gift to humanity, it is clear why the medical sciences began to rule the university roost. The reason this may cause problems extends well beyond inter-academic envy.

To illustrate why this is the case, we begin with Newman’s foundational metaphor for the liberal arts. For Newman, the goal of university learning is not the sum accretion of discrete facts in unconnected fields, but instead the formation of what he calls the “circle of knowledge.” In theory, this circle might be likened to a pie, where each of the liberal arts is represented as a slice of the circle.[1] One slice of the pie is math, another literature, and so on “taking bites” across the breadth of subjects to learn, just by way of example. As Newman himself puts it, “It is a great point then to enlarge the range of studies which a university professes, even for the sake of the students; and, though they cannot pursue every subject which is open to them, they will be the gainers by living among those and under those who represent the whole circle.”[2] Perfection would be a kind of perichoresis of the slices within the whole. This is the ideal liberal arts education, which aims to educate the whole person and provides what Newman calls a “habit of mind” which is “philosophical.”[3]

The practice of the contemporary university does not comport with Newman’s ideal. The modern university has been remade and compartmentalized into grossly disproportionate slices. Students are often not even afforded the opportunity to sample from more than a couple random selections during their education. 100 years prior, Newman warned that we must guard against the domination of certain sciences over and against others, if we are to protect the integrity of the university:

I observe, then, that, if you drop any science out of the circle of knowledge, you cannot keep its place vacant for it; that science is forgotten; the other sciences close up, or, in other words, they exceed their proper bounds, and intrude where they have no right.[4]

Thus, Newman’s view is not of a theologian envious of the medical sciences for its dominance.

Rather, something more systemic has begun to falter in our understanding of university education. As Newman saw, “You will soon break up into fragments the whole circle of secular knowledge, if you begin the mutilation with divine.”[5] When Newman then begins to wrangle with the relationship between Church and medicine, his goal is not to imagine a binary world between the spiritual and the physical, but to imagine the kind of university necessary to preserve the circle of knowledge in all its integrity. 

Why is this integrity important? It has everything to do with the lack of recognizing the “wholeness of persons” diagnosed above. If the physical realm is not the only realm of concern to the human condition, we cannot educate students as if this were the case. Newman reminds us, “Man has a moral and a religious nature, as well as a physical. He has a mind and a soul; and the mind and soul have a legitimate sovereignty over the body, and the sciences relating to them have in consequence the precedence of those sciences which relate to the body.”[6] He goes on to say, “After all, bodily health is not the only end of man, and the medical science is not the highest science of which he is the subject.”[7]

Medical Education and a History of Rival Anthropologies: “Self-Contained” vs. “Integral”

This prompts a question: would medicine agree with Newman’s stated anthropology? Would medicine concede to the university that the physical sciences, though powerful and indispensable to the human race as corporal beings, are not the highest order of science concerned with human nature? Suffice it to say, there appears to be ample evidence that the medical sciences would resist such concessions. To Newman, this results from medicine exceeding its sphere of influence within the university. Modern medicine’s tendency to exclude itself from interaction with other sciences and arts which are not biochemical in nature prompts another question: how can a profession—historically centered around the Hippocratic oath and cradled by the Church—end up with a concept of flourishing focused solely on the measurable and the empirical?

History provides the beginning of an answer. As Jeffrey Bishop writes in his book The Anticipatory Corpse, it was during the French Revolution, in a response to the anti-Church political and social climate, that a “fear of metaphysics” developed, with metaphysics simply defined as that which is not physically realized.[8] With this move away from metaphysical realities, distrust and dislike for hospitals developed as they were considered part of the Church and its metaphysical constructs. Out of this movement, the growth of the clinic emerged and with it a new way of viewing the patient.

In this model, questions of the “why,” specifically concerning purpose and final causation, became irrelevant and out of the scope for the “experimentalist” physician.[9] Claude Bernard, the nineteenth century physiologist wrote in his book The Introduction to the Study of Experimental Medicine, that “To solve the problems of life, physiologists therefore call to their aid the sciences – anatomy, physics, chemistry, which are all allies serving as indispensable tools for investigation.”[10] But of course the physical sciences, although quite able to provide many solutions, cannot solve the deepest and most pressing problems of life. They are experts at the “how” questions, but the “why” questions often elude their grasp. Many of the most intractable problems of life—particularly those centered around death, a reality medical practitioners paradoxically face time and again—exceed the capacity of the biomedical sciences to solve.

In looking in the wrong places for solutions to these questions, medicine sought answers from within itself. The goal: to become “self-contained.” Bernard, exemplifying the impulse, claims that “A man of science should attend only to the opinion of men of science who understand him, and should derive rules of conduct only from his own conscience.”[11] As Bishop concludes, the result of this shift in metaphysics led to a paradigmatic change in medicine and medical education. Thus “medicine has become thoughtless: medicine is primarily about pragmatic doing and efficient control, ordered to utilitarian maximization and its own practicality.”[12] In this new model, medicine became a profession turned in on itself, “freed” from the influences of metaphysics and theology associated with the Church.

Despite this so-called “progress,” there are inklings among modern medical educators that something is amiss. For some, medical education falls short of providing the resources necessary for students to find meaning in their vocation. Questions of “why” or “to what end” appear notably absent. Lacking a sense of its place with and among the sciences in general robs students of a proper understanding of the goals and purpose of medicine.

This reckoning with its own shortcomings, however, can be a tough pill to swallow for a profession that has rightly earned a high view of itself. Newman admits that this is not surprising. “Men, whose minds are possessed with some one object, take exaggerated views of its importance, are feverish in the pursuit of it, make it the measure of things which are utterly foreign to it, and are startled and despond if it happens to fail them.”[13] Medical education is in dire need of a proper philosophical grounding, and must look outside of itself to find it.

A better philosophical undergirding is needed for medical education to flourish. The question is, what should that philosophy be? Students often liken the experience of medical education to drinking out of a fire hose. Not only does that sound terribly unpleasant, but in addition, incredibly unfruitful. Yes, there is a great deal of biomedical science to learn. Yes, the amount of biomedical science that begs for each student to master it has increased exponentially over the past several decades. The number of facts to get one’s mind around is overwhelming.

But is this all medical education should be, a memorization of facts? How does one then “make sense” of what one is learning without a ground on which these facts can properly germinate? How does one learn the limits of the biomedical sciences if one is only immersed within said fields? As Newman enumerates, “There are men who embrace in their minds a vast multitude of ideas, but with little sensibility about their real relations towards each other.”[14] It is only in relation to the aforementioned “whole pie” that one’s shortcomings can be brought into sharp acuity.

Once more, the mounting success of medicine casts the shadow that blinds us to the field’s shortcomings. A truncated circle of knowledge leaves us with an impoverished view of human persons. As Newman writes, “Knowledge, viewed as Knowledge, exerts a subtle influence in throwing us back on ourselves, and making us our own centre, and our minds the measure of all things.”[15] Without a proper, relational grounding, we risk churning out technicians who see their patients as, at best, molecules in motion, and at worse, mere machines. While Newman admits the medical sciences alone prove something true about our animal nature, it is not enough to justify the moral obligations imposed by medicine, precisely as it does not speak to the entirety of the human person. Indeed, this malformed anthropology poses the greatest threat to a proper medical education.

This “self-contained” outlook leads to other dangers as well. Medical Scientists begin to see whatever is true in their own field at once as lawful and applicable to any practice, simply because it can be proven correct in their own domain. He notes:

You will observe . . . that those higher sciences of which I have spoken, Morals and Religion, are not represented to the intelligence of the world by intimations and notices strong and obvious, such as those which are the foundation of Physical Science. The physical nature lies before us, patent to the sight, ready to the touch . . . But the phenomena, which are the basis of Morals and Religion, have nothing of this luminous evidence.[16]

The problem then rests in the very physicality of the results of these sciences. Those with the opportunity to teach modern students immediately recognize the validity of his claim. When attempting to address morals, metaphysics, or the spiritual life, students often find their views of these intangible realities occluded by the predictive power of science. For students informed by the paradigm above, the incongruity between measurements of the physical world and assessments of purpose and mission are hard to navigate. One cannot ask for 30ccs of compassion, for example. Is it impossible, then, to measure something that is not a fluid emitting from a body? Once again, what can be done to convince students in the health sciences that a human being is more than a quantity to measure?

Newman presents instead a vision where education leads to what he calls “an enlargement of the mind,” where “the enlargement consists, not merely in the passive reception into the mind of a number of ideas unknown to it, but in the mind's energetic and simultaneous action upon and towards and among those new ideas, which are rushing in upon it.”[17] This can only happen when medicine breaks from its self-containment. Newman tells us that “there is no enlargement, unless there be a comparison of ideas one with another”[18] where a properly formed student “possesses the knowledge, not only of things, but also of their mutual and true relations; knowledge, not merely considered as acquirement, but as philosophy.”[19]

In this model, Newman goes on to say that “possessed of this real illumination, the mind never views any part of the extended subject-matter of Knowledge without recollecting that it is but a part.”[20] It is in this relational structure that the true telos of medicine can be understood. Without it, education becomes a collection of mere facts, like driftwood scattered upon an open sea, leaving students awash on the waves without a proper compass or rudder.

This has not passed completely unnoticed in the field of medical education. Over the past several years, attempts to broaden the “scope” of biomedical education have been made to “round out” degrees in the health sciences. In this fashion, many medical schools now have “pathways” or courses in medical humanities and ethics to address this perceived lack. Their creation demonstrates awareness of the need outlined above and proves the abundance of goodwill harbored by colleagues determined to improve the lives and practice of their students. However, how one addresses this issue is of key importance.

Fundamentally, the above-mentioned approaches cannot properly take the place within the circle of sciences that must be held by theology and philosophy. By removing these sciences from the circle, the medical humanities and medical ethics “encroach” into the spaces they are not equipped to address. As good as they may be, of their own accord they cannot properly orient medical education.

None of this need be malicious. Newman assures us that “these various usurpations are frequently made in perfectly good faith.”[21] There is no doubt that, through these efforts, medical educators hope to foster students who are “well rounded” and “humanistic.” Indeed, it would be misguided to say that these experiences do not provide some value to the learners. But what is the view of this “human” upon which the students should feel compassion? In other words, only a proper anthropology can provide the telos for whose sake these efforts are done.

As Christian educators, we must assert that these initiatives simply do not go far enough. In light of our stated beliefs, they invariably fall short. Foundationally, we believe Truth is a person. Our philosophy is based on this person, Jesus Christ. Our anthropology is not only based on him, it is him. This Truth brings us back to the question we posed at the beginning of this essay—what difference should it make to our practice of educating medical practitioners if we conform our vision to Christ? To pose Dr. Bishop’s question once more: “Might it not be that only theology can save medicine?” Newman answers definitively in the affirmative.

The Relationship of the Professions and Knowledge For its Own Sake

Returning to the “last word” in The Idea of a University, Newman makes his bold claim:

That great institution, then, the Catholic Church, has been set up by Divine Mercy, as a present, visible antagonist, and the only possible antagonist, to sight and sense. Conscience, reason, good feeling, the instincts of our moral nature, the traditions of Faith, the conclusions and deductions of philosophical Religion, are no match at all for the stubborn facts …which are the foundation of physical, and in particular of medical, science.[22]

The stubborn facts require a “why” behind their “how.” The institutional Church, to Newman’s mind, provides the only reconciliation between medicine’s current state and its deeper roots by giving birth to a higher anthropology, one that exceeds that of human persons as the mere summation of their biomedical condition.

Perhaps the most surprising turn in Newman’s argument is why he imagines the Church to be the “sole antagonist” of medicine within the university. Its role is to be neither that of a hidden evangelist, nor of a meddling chaplain, for Newman does not have in mind a great battle between the facts of science and the truths of the faith some might expect to find. Instead, the Church serves as the sole institution with long enough pedigree and abiding patience to insist on the true cure for the malady transforming medical practitioners into mere technicians: knowledge for its own sake.

In other words, Newman’s vision of the liberal arts—birthed in the same heart of the Church that brought forth hospitals and the Western practice of medicine—is not one mode or theory of learning among many. It is the sole institutional incubator providing a cultivation of mind for its own sake. Beyond any practical, worldly gains for the student, this cultivation is worthwhile precisely because its goodness exceeds any instrumental or technical use.

For Newman, the most obvious metaphor for this idea, that “knowledge-for-its-own-sake” is in addition useful, turns out to be none other than health itself:

You will see what I mean by the parallel of bodily health. Health is a good in itself, though nothing came of it, and is especially worth seeking and cherishing; yet, after all . . . we never think of it except as useful as well as good, and praise and prize it for what it does, as well as for what it is . . . And so as regards intellectual culture, I am far from denying utility in this large sense as the end of Education, when I lay it down, that the culture of the intellect is a good in itself and its own end; I do not exclude from the idea of intellectual culture what it cannot but be . . . I only deny that we must be able to point out, before we have any right to call it useful, some art, or business, or profession, or trade, or work.[23]

Health is an unqualified good, needing no additional benefits to merit pursuing it. But what better person to enjoy the benefits of a good life than a healthy one? Who is more likely to be industrious in work than the healthy? By being a good in its own right, health cascades benefit to all segments of life, but can only do so to its maxim degree if it is attended to first for its own sake. Knowledge is no different. If what we want is better medical practitioners, we have no better way to form them than to provide a love of knowledge for its own sake. As Newman concludes:

Again, as health ought to precede labour of the body, and as a man in health can do what an unhealthy man cannot do . . . so in like manner general culture of mind is the best aid to professional and scientific study, and educated men can do what illiterate cannot; and the man who has learned to think and to reason and to compare and to discriminate and to analyze, who has refined his taste, and formed his judgment, and sharpened his mental vision . . . [will] be placed in that state of intellect in which he can take up any one of the sciences or callings…with an ease, a grace, a versatility, and a success.[24]

Indeed, it is fitting that health and knowledge are seen as such natural analogues. A sterling example of this is demonstrated by St. Thomas Aquinas. The teacher cannot “put” knowledge inside of a student, just as no health practitioner can “give” health to someone who is sick. Instead, just as a physician either removes disease or gives medicine to aid the body in doing what it already does by nature, the teacher either removes error or provides demonstration to aid the intellect in discovery, that which it does on its own by its very nature.[25]

Beyond being a serendipitous analogy, Thomas illustrates a point we have been making all along: neither medicine nor teaching is a mere technical endeavor. Medical education itself cannot then be reduced to a set of techniques, nor can its goal be to produce mere technicians, no matter how much prowess or mastery they demonstrate. To form medical practitioners is to cultivate, in Newman’s words, a particular habit of mind. To create graduates who see patients as more than problems to be solved, we must first see those students as more than repositories of technical skills. If we want professionals who see the whole person, we must have institutions who regard students as whole persons as well.

What will this concretely look like? To call back the pithy statements we began with, what does this look like when the rubber meets the road? On the one hand, once we stop thinking of the ailments within medical education as technical problems to fix, we might begin to see that there are no one-size-fits-all treatments. Indeed, the call to reform Christian education in general from primary school through graduate school, is a systemic change that would benefit not only university education, but as noted above, even our approach to what we are doing when we prepare professionals to succeed in a field. Put mildly, it may be the case that instituting Newman’s vision of liberal education earlier in our academic plans might “free up” professional education to do other innovative developments down the road. If students come to professional school with intellects already well cultivated, focusing on technique is no longer the pronounced issue it once was.

However, in the educational world we currently inhabit, there are no guarantees about what encounters with liberal education a student has had before arriving at our doors. It thus behooves medical educators, from certificate programs all the way through doctoral degrees, to be agile and creative when providing a chance for students to cultivate knowledge for its own sake. Otherwise, the useful benefit of enlargement will be lost when they subsequently approach their technical fields. This of course sounds exceedingly daunting—what school has “extra time” to add more classes?

A simple solution does not exist, but one suggestion seems pertinent enough to leave for our reader’s consideration. As Newman’s focus on liberal education rests in the wholeness of the circle of knowledge, we should not confuse that with a demand that the circle be a particular size. In other words, Newman is not advocating that we make sure the pie is cut into a certain number of pieces, all of the same equal measure, and meticulously fuss over the composition of each slice. The point for Newman is the whole pie—and it is much better to have a small whole pie rather than multiple, incomplete large chunks.

The habit of mind Newman aims at does not hinge on a set number of hours taken across fields. What is most important is the quality of wrestling with the wholeness of the circle. In programs with many hours taken up by accreditation demands, the emphasis should not be on stuffing in discrete pieces of the sciences wherever they may fit. Instead, the exercise of engaging with the whole circle for the sake of illumination is paramount, an understanding of the interconnected relationships between the sciences key. Whatever we may choose to do in prudential curriculum decisions, the wholeness itself, and the effects of such an encounter with that wholeness, is the overriding goal. Once more, if we want our students to see their future patients as whole persons, we must model this by seeing them in the same light.

As the world emerges from the heavy cloud of the pandemic, more and more light will begin to shine on the medical profession. For Christian educators of the health sciences, the success or failure of our efforts will rest in precisely this: which students did we treat as ends in themselves rather than as means to our ends? If we follow the insights Newman lays before us, then to marshal one last metaphor, the proof will be in the pudding. Those students we loved and respected enough to provide the gift of knowledge for its own sake? They will have proven themselves exceedingly useful in tending to a world of crippling need during the COVID-19 pandemic. For those students who were not given this respect, we cannot necessarily expect the same. For there is nothing like a pandemic to prove the saying of Scripture: “seek first the kingdom [of God] and his righteousness, and all these things will be given you besides” (Matt 6:33).