Moral Formation Is Not a Technical Project

Ben 0:00
Hey y’all welcome back to beyond surviving residency, the podcast dedicated to helping residents like you find more rest, fulfillment and clarity amidst the chaos of residency. I’m your host Benjamin long. Through this series, I hope to equip you with practical tools to move away from just surviving residency, and move toward flourishing. Despite it. I had the opportunity to sit down with Dr. Warren Kinghorn to talk about medical education as moral formation and what Aristotle may have to say about that we touch on how medical education is viewed and treated as a technical project, and what steps we can take to become a person of practical wisdom. Dr. Kinghorn is a psychiatrist with multiple published articles and a recent book called prescribing together a relational guide to psychopharmacology. He’s also co director of Duke University’s theology, medicine and culture initiative, which you’ll hear more about at the end of this episode. And y’all, I just really tried to soak up every word during this conversation. And hope you do too. So let’s get started.

Dr. Warren Kinghorn, thank you so much for coming on to beyond surviving residency.

Warren 1:28
Thank you for having me on the show, Ben.

Ben 1:30
Yeah, you know, I got to say that it’s so amazing the ability we have with technology now to connect us and that I discovered your article on the Aristotelian account of medical professionalism, you know, randomly online, and I was just kind of searching through some questions that I had about medical education and moral formation. And so then found this article, and then wanted to know more about the author, and then found the Duke theology, medicine and culture initiative. And now, you know, a year or two later, we’re talking across the country. Just amazing that I’m so grateful that that’s possible.

Warren 2:11
And thanks for finding that article. And I’m so grateful for this connection and to hear about the work you’re doing and to be part of the podcast. It’s, it’s really exciting. So thank you very much.

Ben 2:21
Yeah. So I’ve introduced you to the listeners. But I would really like to hear a little bit more about what led you to become interested in writing this article, specifically, and maybe even more broadly, the intersection of religion and spirituality within medicine.

Warren 2:42
Yeah, thank you. Well, the article that you mentioned, that I think we’ll be talking about later in the episode is not specifically about theology or religion, it really draws more on the moral philosophy of Aristotle, or than anything else, but my own work is deeply tied to religion and spirituality and health care. I have been interested in this connection, really since before Well, before I was in medical school, I grew up as a Christian, I grew up taking my faith seriously, I wanted to connect it to what I was doing in the world. And as I got more interested in healthcare, and maybe the possibility of becoming a physician in high school in college, I was interested in medical ethics. I thought that was the primary way that religion would connect with medicine. And then I just found that the questions just kept getting broader for me, I had an amazing opportunity as an undergraduate, to work for a summer with hospital chaplains. I was working in a chaplain service in a community hospital, and I was doing something very similar to Clinical Pastoral Education. And so I was working with chaplains, I was talking with patients, representing the chaplains. And this really opened my eyes to the way that people’s faith commitments, faith communities, commitments, and values affect the way that they engage illness and death and suffering and, and so I got to medical school, having had that experience, and I began to ask, like, bigger questions of medicine, like what is health? And what is medicine for? And what does it mean to die? Well, and what does it mean to live well, and I was in Boston at Harvard Medical School, and in this huge urban, complex of academic medical centers. And I began to wonder, like, how does medicine operate as a power in the way that the New Testament describes powers and principalities? And how is it a force for good and how might it be a force sometimes for harm? And all that led me to ask, you know what I might considered the why questions of healthcare? I found that my experience in medical school was teaching me how to ask and answer how questions like how do we apply a certain technology at a certain time? How do we diagnose this particular condition? How do we prescribe a certain medicine? But it wasn’t as good at helping me to ask and answer the why questions like, why are we doing what we’re doing? And who are we doing it for? And what’s the end of our activity? And that eventually led me to study theology. And that’s been a kind of an ongoing conversation for me, since I was in medical school and before.

Ben 5:20
Yeah, that is so rich. And that, you know, we we put that on banners and hospitals or in mission statements, and, you know, saying we, you know, want like high quality health care, and yeah, yeah, exactly. Like, we we don’t have time or a structure or anything in a lot of places to really say like, what is health? You know, like, what exactly actually aiming for when we’re saying these things?

Warren 5:51
Yeah, I mean, you know, I’m constantly being referred to, and I consider myself a health care practitioner, or nowadays a health care worker, and, you know, work in a health system. And yet, it’s amazing how, for me, and I asked trainees, when I talked to folks who would be interested in your, in your experience with this, then but, but I asked medical students, especially and residents, when was the first time in any curricular setting or classroom setting that you were ever really had to answer and define what is health? And in my field of psychiatry, it’s also the correlate question, what is mental health? For me, I get various answers to that. Sometimes people say that they’ve never been asked that question in medical school context. And for me, I went through, I think four years of medical school and two and a half years of psychiatry residency before anyone ever directly asked that question, we asked a lot about what is disease and what is disorder? And what are therapeutics but but the question, what is health is a lot more complex. And if you actually look at the literature on it, there’s not agreement on that broad question, what is health? And and I think that we, for the most part, avoid asking that question in healthcare, because it gets to deep questions of moral value and commitment about what does it mean to live a good life? And we’d rather not ask that question in our healthcare systems. And so we’re in this whole complex network of health care, and maybe aren’t even sure what the central term means that we’re pursuing, which is held?

Ben 7:26
Yeah. And I would say like, I don’t think I’ve ever been directly asked that question throughout all of my training. You know, certainly we have, we get, I think we get close to it at certain points when you’re having discussions about how this disease impacts a person’s life or when we try to have discussions on quality of life or things like that. Yeah. But even that, I think, come short of the actual question itself. Certainly.

Yeah, yeah. And in that case, it’s often we tend to look to the patient and maybe the patient’s family to help define what health is for a particular patient, which I understand that and that, I certainly want to honor, the patient needs to be central to helping us understand what health is for them, but simply offloading it to the patient and not pretending that we carry our own values about what is held into our clinical work, I think is is I think we’re deceiving ourselves. I think we actually have more, we bring more in than we think we do. But we don’t have a way to name that in our clinical work. Right. Absolutely. And I think with that there’s a danger because we don’t recognize that we are bringing those values to the table. Yes, absolutely. And because we have focused so much on preparing physicians, to be scientists to be very focused on research and creating knowledge, which is good, like, definitely I need to know, you know, the right medications, the right workup, the right way to come to a diagnosis for a patient that is definitely essential to the practice of medicine. But we confound that with people’s experiences. And the fact that, I think it was Pellegrino, who said that medicine is a moral enterprise, and that we just bring all of these values to the table, and then we make claims about what they should mean for our patients, without realizing that we’re being dictated by those things, essentially.

Warren 9:41
Yeah, and I agree with Pellegrino there, and I do believe that medicine is an intrinsically moral practice. And if we pretend that it’s not if we pretend that the practice of medicine is a technical matter, that we can abstract our commitments or values from and just you know, apply the technology, then I think that we’re deceiving ourselves. I think that we are allowing our own commitments to then have a kind of unexamined power over what we do. And so the better course I think it’s to examine what are the commitments that we’re bringing in to our practice and trying to bring those to light and to be honest about them, and honest and community about them. And to just admit that there is no value free or commitment free way of practicing medicine, nor should there be, but we do need to be transparent about what those commitments are.

Ben 10:35
Absolutely. And I think this is really bringing us well towards this article that you wrote on medical education as moral formation. And so maybe for some listeners, this isn’t a topic that they have really kind of dove into quite yet. So could you put in some context for us about what exactly we are talking about when we’re saying moral formation? Yeah,

Warren 10:59
Thank you. Well, the particular article that you’re referring to, which was published in “Perspectives in Biology and Medicine” a little over 10 years ago, was one that I wrote very soon after I finished psychiatry residency. And so I’ve been deeply immersed in the world of graduate medical education, and still really am as a as a faculty member at Duke. But I noticed that the the language of professionalism, especially at that time, and I don’t think it’s changed that much, but at that time was kind of a hot term in medical education, and about maybe 20 years ago now. So around 2000, a lot of medical education groups and specialty organizations began to be worried about what might just consider like morally poor behavior among physicians, whether that was treating patients with disrespect, whether that was getting caught in ethical conundrums and misdeeds that were then bringing medicine itself into disrepute. And so a lot of, you know, leaders within medicine began to say, well, we need to work on this. And they would often blame what’s often called the “hidden curriculum”, which I’m guessing a lot of listeners have already heard the term. The hidden curriculum is basically the kind of practices that you’re often taught in healthcare, on the wards and in the actual practice that undermine some of the values that you’re taught in the curriculum of medical school. And so the hidden curriculum is often thought to be corrosive of virtue and a character. And so the solution to this was often to put together various policy statements and efforts and sometimes curricula, on medical professionalism, and this is perhaps most visible when the ACGME, the residency, accrediting body designated professionalism is one of the six core competencies of medical training, that system has shifted a little bit since then, but it’s still still there. And, and I just found myself pretty cynical about those approaches, not entirely disapproving, because I think that they were aiming at something really good, which is we do want physicians to practice with character, and we do want physicians to embody these these values that we would consider the values of professionalism. To me, it’s more that I just doubted that those efforts really would were very effective for a few reasons. And I think one is that when people use the word professionalism in medicine, it’s never very clear to me, that we know what we’re talking about beyond simply saying that this physician is a good physician or this physician is like a competent physician or that, you know, the language of professionalism is often very kind of abstract and platitudinous, and, you know, emphasizes these kind of broad commitments. But when you actually get down to brass tacks, and you figure like what actually is professionalism, then it turns out that I think there’s still significant disagreement on the ground, especially in in the kinds of situations that matter. So. So for example, like isn’t attending on rounds, who harshly questions and in turn, acting professionally or not, you know, people would have different opinions that that is a medical student who declines to do unnecessary physical examination that would potentially benefit her training, acting professionally or not. And I think these broad kind of value statements don’t always answer those kinds of questions. And I think also, it’s that, you know, medicine tends to operate. I think we’ll talk more about this. But medicine tends to operate in what I would often call a technical model, which is that we we pre-specify an end or a goal that we want to attain. And then we design a process or a technology to achieve that goal. And then we try to just put it into place in a scalable way. And I think because that’s how a lot of medicine works. That’s how people think professionalism education can work too, that you just decide what you want, and you design the process to get there, and then out comes this product of professional physicians. And I think that that just isn’t the way that moral formation happens in human life, not just in medicine, and to treat professionalism as a kind of product that you can just design, I think, is a wrongheaded way to think about it. I actually think that increases cynicism and burnout among medical trainees in the long run, because they see through it.

Ben 15:22
Yeah, yeah. And the idea that the main thing that’s going to help shape our identity, as a physician are going to be a few lectures scattered across a couple of years, or something that you read or, or whatever, just the, just the quantity of time that you spent in residency seems kind of, I don’t want to say naive, but it seems like that’s not going to have as much of a force versus the fact that you are in this environment and kind of going through the socialization process and every day interacting with patients, colleagues, attendings, nurses, other staff and not thinking that that is going to have just as equal if not more of an impact on who we are going to be as physicians in the future.

Warren 16:16
Yes, absolutely. It’s not that things like white coat ceremonies and talks at different times that reinforce various kinds of aspirations of medicine aren’t well intended, and, you know, maybe constructive, but the way that we learn to be in medicine is not formed at those times, at least, it’s not formed primarily those times, it’s formed in call rooms late at night, when an intern is seeing her chief resident, respond in a particular way to a stressful situation, or it’s when in psychiatry over the course of a year or two, resident or a student is learning from a supervisor about how to see and how to respond to, in particular ways to particular situations. And it’s also frankly, what happens outside of medicine. So what’s going on in someone’s life in the context of their medical training, that’s helping to shape their imagination to see humans in particular ways. And so I think that communities outside of healthcare are so deeply important for how we’re being formed morally for the work of healthcare. And so I think that attention to all of that is, is important and argue, and I think I would claim much more important than the things that are just kind of earmarked as professionalism education in medical school and residency.

Ben 17:42
Yeah, absolutely. And so you started kind of talking on this a little bit, but I think we can go ahead and dive into that, that you contrast this view of professionalism as a product of the medical educational process against professionalism as a way, I think you say, a way that morally excellent clinicians practice through this Aristotelian perspective of the techne and the phronesis. So can you kind of dive into that for us?

Warren 18:11
Yeah, thanks. Thanks for giving me an opportunity to do that. It’s it’s a complex argument, but I’ll try to boil it down. A lot of my thinking about medicine and medical ethics is related to the Greek philosopher Aristotle, and also to, especially to the Christian philosopher, and theologian, Thomas Aquinas, who drew on Aristotle heavily for his own thinking, and their thinking is, is complex, but I break it down as follows. So, as I said, just a minute ago, a lot of modern medicine is characterized by what I would call a technical project. And I’m drawing here on a book by a philosopher and actually an educational theorist named Joseph Dunne – in the D-U-N-N-E – in the 1990s. So I want to give credit where credit is due. But when done writes about this idea of a technical project, he says, there’s three things that are necessary for that. And this is what Aristotle would have called the virtue of making or technique from which we get our words technique and technology, and so on. So there’s three things first, you decide on an end or an outcome that you want to achieve. You then design a process or technology to produce that outcome. And then also, importantly, the process or technology is scalable, and the implementation doesn’t depend on the moral character of the one who uses it. And so we see this all the time in medicine, I think this is the default way that we operate in medicine when we think about developing treatments and therapies and diagnose diagnostic tools. That is like we specify an outcome that we want to achieve. So you know, say like decreased mortality from cardiovascular disease, and then we design a process or technology to try to achieve that. So you might look at stents, for example. And then we develop processes by which that technology can be scalable, often in commercial ways, that then allow that to be applied over a broad population. And so this is the idea of a kind of technical project and medicine is built on that idea of a technical project. And, and to be fair, Aristotle himself thought that medicine was largely about this about making health, he understood medicine as a kind of techne. But there’s another way of thinking about medicine that’s very different. And I think that there is a role for thinking about this idea of techne in medicine, I think interventional cardiology may be one good example of that. But there’s an additional way of thinking about excellence or virtue. And that’s not the virtue of making, which Aristotle would call techne. But it’s the virtue of doing or even of being, and that’s what Aristotle would have called practical wisdom, or phronesis would be the Greek word. And here the point is not pre-specifying an outcome. And then like designing a process to get there, by the most efficient means, or even becoming a kind of craftsmen who can just achieve that outcome. But the point here is to become a certain kind of person, and specifically a kind of person who is wise and who, when facing complex situations can discern in that moment, the right way to feel and the right thing to do and the right approach to take. And so phronesis is fundamentally not about like knowing where you’re going necessarily in specific ways. But it’s about being the kind of person that when you’re put into a complex situation, or a stressful situation, you can see and discern the right thing to do. And so I think those of us in health care know and respect people who are people of phronesis are particularly wise, physicians and nurses and others who like just seem to be able to step into situations and in that moment to know the right thing to do. And Aristotle understood phronesis is different from techne in, in several important ways. Both require teaching, I mean, so for him, mentorship and teaching was just fundamental to all kinds of formation. But where the virtue of making – techne – is fundamentally about learning a process. Phronesis, which has the virtue of being or doing is fundamentally about developing character, and learning from wise people how to respond in the world. And another thing that’s important, there’s a couple of other ways in which these are different is that phronesis or practical wisdom can’t ever be specified, apart from the activity of the practically wise person. So whereas I could say, you know, I want to build a really amazing violin. And so I’m going to develop the skills necessary to do that, I can separate the product from my activity. But if I say, I want to be wise, I want to be somebody who’s able to respond well, I can’t ever, like specify what that looks like, apart from the activity of responding in those ways in the world at a particular time. And so it really is about the formation of a particular kind of person and not just a product. And also, Aristotle understood phronesis as requiring all of the other virtues. So whereas like one might be able to be a wonderful violin maker, and not to particularly be courageous or self control, although I would question that maybe in complex activities, he definitely said you can’t be you can’t live a life of wisdom unless you’re attending to the other virtues. And so if you’re not someone who’s developed the capacity for courage, I mean, to be able to stand strong in the face of danger, you’re not going to be able to develop that kind of wisdom of character. If you’re not someone who’s committed to justice, you’re not going to be able to be that practically wise person. If you’re not someone who’s able to restrain immediate desires and needs, you’re not going to be able to do that. So the formation of wisdom is the formation of the moral life as a whole, which seems like a high calling for the work of medicine, but I actually think it’s, I think it’s necessary. I think, if we’re honest with ourselves, that’s what it means to be a wise clinician. And he also understood phronesis is a lifelong project, it’s not something that you learn and get a degree and then you’re done. But it’s an ongoing process of seeking out wise mentors of being in situations that are conducive to that. So I would just say in medicine to become a practically wise person to become someone with phronesis is not to like enroll in a particular curriculum or go to a particular weekend conference or something, but rather it’s to root yourself – to root myself – in communities that are pointing toward the good, like, what does it mean for me to be immersed in communities that can help to just point me toward what’s good and what’s right and what’s just, and also to hitch yourself to wise teachers whom you want to emulate and to learn from and with them, and I could say, as now a mid-career physician, that doesn’t change after you finish residency. Yeah, and also to seek medical cultures in like medical practice situations that are healthy enough, where that kind of ongoing work of seeking wisdom is possible within them. And I think some situations may not be that way. And so it might be, there’ll be an important red flag if that’s the case.

Ben 25:37
Yeah. Man, thank you so much for thinking deeply about this.

Warren 25:44
That was a lot. Sorry.

Ben 25:45
No, no, it’s so good. Because I think this is exactly what we need more discussion of in medical education. And that idea that this is a lifelong process that you are having to intentionally pursue, you know, you don’t just accidentally become a person of wisdom, it requires some intention behind it. But that’s kind of scary, because there is this aspect of not having control, you know, with the, with the techne, you can design this process, and in some ways you’re going to, you’ll be able to create this product and have some consistency with creating that product. Whereas I think, the process that you’re describing for obtaining practical wisdom, there’s not as much control and so yeah, I think in a world where we want to be standardized, and to have as little risk as possible, it’s, I think, probably hard for some people to bite off on that.

Warren 26:49
Yeah, I think that’s right. And so I think that some, I can imagine some people hearing this and some thing like, “that sounds so moralistic,” or you know, sounds like heavy handed, and it’s all about, you know, this talk about morals and virtues. And I get that, and I think it’s just important to note that for Aristotle, like the point of virtue is not to be constantly like, you know, this, like, shame driven way to be monitoring yourself and thinking, I’m not like, you know, the point of virtue is actually to become the kind of person who acts through second nature toward what’s life giving and good. So when you think about virtue, for Aristotle, it’s not like, when you say the word virtue now in our, in our culture, it has all these connotations of like, shame and judgment, and “Am I virtuous?” and for Aristotle, the virtues were like these ways of being in the world that gave freedom that made it possible to just be the kind of person who doesn’t have to be constantly like chastising oneself and monitoring oneself, but someone who can act with what Aristotle said, ease and pleasure toward what’s good in life giving, and who doesn’t want that, you know, to be a kind of person who’s just able to navigate in the world toward the good with ease and pleasure. And I think that’s what I think we all want for our trainees that we want for ourselves. And that’s what Aristotle’s, you know, pointing to as a possibility for clinicians.

Ben 28:13
And I’m curious, you know, you kind of are mentioning people who may be listening to this and are skeptical. I’ve said previously on this podcast, that part of where we’re at with this, and talking about moral formation, moral knowledge is so difficult for us to really take in because we don’t have this agreed upon common moral knowledge to draw from with that, and being in a field where there’s such this kind of scientistic worldview, that everything has to be proven by evidence based medicine that can be tested in the lab and is observable with your senses. I guess. If someone like that is listening to this podcast, how would you maybe challenge them to start this process of thinking about moral formation? And what we’re talking about here?

Warren 29:10
Yeah. For someone who is deeply committed to medicine or health care as a technical, scientific practice, that has little if anything to do with particular moral commitments – I would want to know more. As a psychiatrist, I’m always wanting to know more about story and about what leads people to think and act in the way that they do. And I would want to know, what is it that’s behind that need for medicine to be like “value neutral”, “scientific”, “value free”? And I think that I think that’s the place to start. That’s a question that I would ask in the abstract, although it’s hard to ask oneself that if people are really resisting like, “No. Like, medicine is just, it’s just a matter of science,” then I would wonder, why do we need for that to be the case, given I think reason to believe good reason to believe that our clinical practice is always shaped by particular moral values and commitments. And if that influences what we do, if someone’s really needing to believe that it’s only science, I want to know, like, what’s going on there? And that’s just a question I would ask of, of anyone individually, I think I would also just want to say, what might be some unexamined or hidden values and commitments that might be not acknowledged and named? And what would it mean to be able to come to terms with those? And again, just as I said earlier, I think that it’s not bad to bring moral commitments into medicine, it’s inevitable. And so the best we can do is to be transparent about what’s leading us and what’s driving us.

Ben 30:56
Yeah, absolutely. And I think what I’m hearing you saying too, is there’s some aspect of, we need each other and community to kind of work through these questions, because everyone has a certain level of self deception of really, what is informing our daily lives and our actions and our behaviors. And an essence of self-deception is you don’t know. And then once you know, then it’s no longer self-deception. So it’s this hard thing to kind of navigate. And really, there isn’t – that I’m aware of – a way to overcome that by yourself, you have to have other people who are challenging and discussing, and you know, kind of pressing at that. And I think that is something that we need to recognize, if you are a person who’s saying, like, “I’m committed to, to science and objectivity, and being able to look at the burden of proof through science,” then I think you would also realize that at a certain level, you have to have some amount of faith in the process. And that, if you are, you know, just like within science, if there is a new discovery or something else that tends to overturn the old ways of thinking about that. So it’s this dynamic process. And so just in the same way, that same faith that you’re putting into science, and that kind of moving forward, that applies to the inner life and our moral commitments and the things that we are talking about here as well, I would think.

Warren 32:42
Yeah, and I think that being participating in communities outside of medicine is really important for every physician, especially given the amount of power that physicians have in healthcare systems, I realized that that power is under threat in many ways. But I think that, for me, I mean, academically, it’s actually a gift that I do my work not only in the medical school at Duke, where I’m kind of surrounded by the academic medical culture, but also in the Divinity School where I have a lot of colleagues and students who are, who are not in that culture and are able to ask questions that forced me to confront the culture of medicine in new ways. And, and I think also, I mean, for example, I think that my experience is that, although this is this has changed somewhat in the last year or two, but that my colleagues and students in the divinity school at Duke, were asking, like, deep questions about class and race and racism in history before many people in the medical center in the in the circles that I was around, were asking, and so I was forced to ask questions about, for example, like, how do we think about the particular local history of race and class in Durham, North Carolina, where I was practicing, having a foot outside of the medical world and hearing people ask questions about that helped me then to ask questions inside the medical world. And my experience is probably more in the academic world than it than it should be. But I think also getting outside of the academic world entirely and being engaged in community organizations and groups and circles of conversation where people are completely outside of medicine and able to help us as clinicians see what we’re not seeing and what we’re missing. That actually does matter and inform matter for and inform our practice is really, really important. And I think for me, it’s been how do I continue to develop the kind of posture of humility of Yes, I have lots of training. There’s lots of things as a psychiatrist that I can do, that I’m delighted to be able to do, but there’s also an awful lot that I don’t know. And as you said, I’m never aware of what I’m not seeing until someone points it out to me and I’m like, “Oh! well, yeah, I wasn’t attending to that and I need to!”

Ben 35:00
Absolutely. And I’m, I’m interested in all these things that we’ve talked about so far, how has attention to these things really impacted your practice of medicine?

Warren 35:23
Yeah, I think for, for me, and again, we’ve been talking mostly about Aristotle today, but I’m also deeply informed by Christian theology and Christian practice. And I think for, for me, above all, I think attention to spirituality to faith to these broader questions of moral formation should in first person, I like to think that it helps to make me as a clinician, a better listener, especially a better listener for patient stories and the stories of their communities. So I like to think that patients – and again I’m thinking as a psychiatrist – are not just bearers of symptoms, but inhabitants of complex and beautiful stories. And patients are not just machines to be fixed in a technical way. But wayfarers that goes on a journey to be attended. And I have an opportunity, as someone who’s also on a journey to be able to come alongside them, and to act as a kind of guide and advisor, to say, “Hey. I’m walking with you, and what are the options ahead of you? And what what kinds of options can we discuss.” And so for me, taking the perspective, not of someone who fixes technical problems, but as someone who is someone who walks alongside those on a journey has been deeply important. So for me trying to resist in psychiatry, the temptation to reduce really complex experiences and behaviors, to just a checklist of symptoms, as the DSM handled wrongly, can often be seen as doing is important. And I think also, not allowing myself as a psychiatrist to get sucked into the idea that the thing that I am at my core is a medication prescriber, who I am as a psychiatrist is someone who brings in a lot of different kinds of wisdom, hopefully, and also areas of ignorance, as I’m attending to a particular patient’s experience. And so how do I bring my whole self into that encounter, and then to come out with a with a strategy that often does involve medication, but also involves talking with patients about their communities and about their, the stresses of their lives and about their life stories and about their social support and about their faith sometimes, and how do I think of myself in a more whole person way, then technical approach to medicine would allow?

Ben 38:02
Absolutely, and I love that imagery of us on a journey, and we are walking alongside with our patients. And I think that is such a beautiful gift for physicians to help kind of mold our imagination a little bit. And then the episode before this, I’ll have just introduced the concept of the components of a good physician of what we are trying to move toward in our journey, which really appreciative of the TMC, because a lot of it was based off of a lecture that Dr. Lee gave back in 2018. So definitely, very appreciative of that. But I’d love to hear your feedback or response for the argument I’m trying to build, which is essentially that any discussion of a good physician must include who we are as persons with intentions and settled dispositions of behavior, or in other words, that an essential component of who we are as physicians is who we are as persons.

Warren 39:08
Yep, I would. First of all, thank you for sharing me sharing with me a little bit about what you’re been covering the previous episode. And I am so grateful to my do colleague, Walter Lee, for his approach to thinking about virtue in the context of residency education, himself as an ENT surgeon. And I think he’s doing really, really good and incredible work and is also someone who brings his own deep personal faith commitment into the way that he thinks about providing good care for patients and I really respect him a lot. I would just say thank you for sharing that with me. And I agree, I think a lot of what we’ve been talking about today is that how we practice as physicians is really, ultimately inseparable from the kinds of human beings that we are. I do believe that one can practice certain forms of technique and In medicine, well, perhaps without as much direct effect from one’s moral character, but I don’t think that one can practice medicine over a career, and not attend to kind of people that we are and have a kind of career that is constructive and whole and fulfilling in the deepest sense. And for those around us. And I think especially in my field of psychiatry, it’s very hard for me to imagine how one could be a psychiatrist in practice over a matter of years and not cultivate being a certain kind of person who is, you know, really attentive to those virtues of furnaces and not just a technique. So yeah, I would, I would just really encourage everything that you’re doing that we’re talking about today and what you’ve done. I think one thing that I did see in the, your approach that I would maybe have a small point of conversation about is that point you said that you were talking about the difference between virtues and values, and good said that values or disposition or belief, whereas virtue is what you do. And again, thinking from the perspective of Aristotle and Aquinas, one thing is that I don’t personally, although I’ve used it a couple of times, in our conversations today, I don’t like the language of value. Because it’s so often contrasted with fact, and it’s has a very modern history. And history, frankly, that’s tied up in values of exchange and prices, that kind of thing. I’d rather use the language of commitment, I think that that is often replaceable for value and actually a more helpful term to us. And so in that way, I’d see virtues and commitments as mutually related to each other, that our commitments are the ends are the goals that we are hoping to attain, that the virtues which are dispositions, or habits and patterns of behavior, the virtues are seeking. And so our commitments are the inner gold, that to which the virtues are pointing. And the virtues which Aristotle would define as disposition, or as embodied a habit or disposition to act in a particular way, in particular situations. The virtues are those habits, which enable us to be able ultimately to attain those commitments. And so they they kind of both need each other virtues need commitments to understand where they’re going, and commitments need virtues to actually have a chance of being attained. So that I would want to add to the conversation in that way. But overall, I think it’s fantastic. And I’m so delighted to Ben to know of your work and to be part of this conversation. Thank you.

Ben 42:34
Yeah, thank you. And I really appreciate that perspective. And I think a good note on that, you know, kind of coming back to maybe someone who’s a little bit more skeptical, to remind them that we are going to bring our commitments and our virtues that we have, because each person has them. So shouldn’t we have a system that is open to discussing those things? And to say, “how do these commitments how do these virtues impact our patients and impact where we are going as physicians?” I think that’s critical. Well, we’re kind of winding up here. So thank you so much, again, for being on the podcast. And I end every interview on beyond surviving residency with two questions. So the first one, just kind of tell us what’s one thing you’re doing to move toward flourishing instead of just surviving right now?

Warren 43:31
Yeah, thanks for asking that question. Well, we’re now as we talk almost two years into the COVID pandemic, which has, for me, affected me in various ways, but it’s forced me to be on screens a lot more. And I am constantly trying to find ways to avoid being on screens too much. And so a couple of things that I’ve really enjoyed recently is I’m kind of an introvert. So I’ve really enjoyed being out and walking in some woods near where I live, we’re fortunate here in Durham to have a lot of walking trails around us and I’m really become much more connected to the value of being in the natural world. I’ve also, for exercise, have started taking swimming, which is like the ultimate anti screen activity, like away from a computer keyboard. And for me, that’s been really restorative. And I’ve also been, I found just recently that in part because I’ve kids that are, you know, getting into this phase of reading, but I’ve started to look back to novels that I loved as much earlier in life. So right now I’m rereading Allen patents cry the beloved country, which I’ve not read in well over 20 years and just finding a lot of joy and returning to some things that were for me, like really beautiful and sustaining earlier in life.

Ben 44:49
Huh, that’s so good. Awesome. And then one last thing is a big aim, kind of what we’ve been talking about of this podcast is to explore what it means to be A good physician. So can you tell me about a good physician you personally know in medicine?

Warren 45:05
Yeah. Thanks for that question. I, there’s so many examples, but one person that I think of specifically is a colleague of mine at the Durham VA, Seamus Bhatt-Mackin, who is a psychiatrist who is about my age, and we finished the residency at Duke at about the same time. And one of the things that I love about Seamus is that he is a deeply committed psychiatrist, he knows his craft, he knows the world of Psychopharmacology really well. But he also is just someone who’s constantly just asking broad questions of the field. And he’s also sought out ways of practicing and conversation partners that I think encouraged him to think about psychiatry in a different way. So he’s, for example, become a specialist in group psychotherapy, which is really uncommon for psychiatrists to have that kind of training. But that shapes everything about his practice. And he’s actually carved out a way in the VA system to do like weekly individual psychotherapy with patients, which is not our culture that psychiatrists typically don’t get to do that, but he’s really intentional in crafting a kind of practice situation that is, is that serves and meets human needs. And, and I just really respect him for that. He’s always been somebody that I’ve always appreciated, talking with, he helps me to be more aware of my own commitments and my own ways of not seeing and psychiatry, and I’m always grateful for friends like that.

Ben 46:28
Wow, that’s so great. And I think this is such an interesting trend, because so far you’re the third person I have interviewed, and a theme that is emerging certainly is curiosity. That people who are naturally kind of seeking out these questions, I think there’s some correlation there. So thank you so much for that answer. And again, for coming on the show. I really appreciate it.

Warren 46:56
Really, thank you so much, Ben, for having me on. It’s really a blessing. And I appreciate the opportunity. And certainly, if any of your listeners want to be in contact with me or want to learn more about our work at in the theology, medicine and culture initiative at Duke, I’m very happy to be in conversation with anyone.

Ben 47:13
Yes. And thank you for bringing that up. Because I meant to ask you, can you tell us real quick, a little bit more about the theology, medicine and culture initiative at Duke?

Warren 47:21
Sure, of course, yeah. So part of my work in Duke is in the Duke Divinity School. And I co direct an initiative called the theology medicine and culture initiative, we exist to connect the world of healthcare with the world of Christian faith and practice. And we are committed to seeking the renewal of health care through the renewal of the church’s health practitioners. So we because we’re in a divinity school, we can do very intentionally faith based formation and work in the heart of a research university. And that’s for me, it’s really exciting. And so if any of your listeners are identify as Christians in health care and want to dig more deeply into their own faith and into the resources of Christian tradition, we have several programs. For those who are in health formation or students or who have the capacity to come to Durham to live and study with us. For a year or more, we have a full time residential program called the theology, medicine and culture fellowship, in which students are taking courses in the divinity school learning with each other and community, engaging in spiritual formation, engaged in various community organizations. And it really is a really deep formation program for imagining and engaging the world of healthcare in Christian context. And then we have another program called our hybrid certificate in theology and healthcare. And that’s for people who are practicing full time or who aren’t in positions where they can move to North Carolina for, you know, two semesters, but who are interested in this kind of work. And so we have a program that allows people to be here on campus with us at Duke for two weeks, a year, once in August, and what’s in January, and then to take online coursework for the remainder of two semesters. It’s a program that allows for a deep exposure to theology and church history, Christian history biblical study. It’s a deep exploration of Christian faith as it relates to health care in lots of different ways. It’s a deep engagement with spiritual formation and practices that can be sustaining in health care, and its connection to community. And so we are really excited about that program as well. And so if anyone has an interest in wants to be connected, you can find us on the web at TMC, divinity duke.edu, or reach out to me personally or to us, and we’d be happy to connect anyone to further conversation about our work.

Ben 49:45
Absolutely. Thank you so much for that, and we’ll definitely include a link to that in the show notes.

Warren 49:51
Thank you so much.

Ben 49:52
Thank you.

Alright, y’all come on. Wasn’t that so good? Oh, man, I’m just so thankful for the opportunity and really for you too for coming back each week to listen to these episodes and interviews. And I would really love it if you could share your thoughts on the podcast by leaving a review on Apple podcasts to help more people discover this content. So if you go to the show notes for the day, there’s a link that you can click and leave a review and help more people learn how to move beyond just surviving residency and maybe towards flourishing despite it. Thanks again for listening and I’ll see you all next week. Bye, everybody.