David C. Leach, M.D. (left), is the retired CEO of the Accreditation Council for Graduate Medical Education (ACGME). Born in Elmira, N.Y., he received a B.A. from the University of Toronto in 1965, and an M.D. from the University of Rochester School of Medicine and Dentistry in 1969. He completed residency training in internal medicine and endocrinology at the Henry Ford Health System in Detroit, Mich., and is certified in those disciplines. He also had additional training in pediatric endocrinology.
Dr. Leach received the “Good Samaritan Award” from Gov. John Engler for his more than 25 years of work at a free clinic in Detroit. He served as assistant dean at the University of Michigan for several years, primarily directing the Henry Ford experiences for Michigan students, and he was a residency program director and Designated Institutional Official at Henry Ford. Dr. Leach is interested in how physicians acquire competence and are enabled to be authentic practitioners of the art, science and craft of medicine. He received grant support for innovative curricula for both medical students and residents from the Robert Wood Johnson Foundation and the Pew Charitable Trust. He is interested in “chaordic” organizations, the teaching of improvement skills, aligning accreditation with emerging healthcare practices and the use of educational outcome measures as an accreditation tool.
Dr. Leach has received honorary degrees from four medical schools and is committed to honoring program directors through the Parker J. Palmer Courage to Teach award. A member of the Gold Humanism Honorary Society, he is deeply interested in the use of values as well as rules in guiding the behavior of physicians and teachers, and he believes that we teach who we are as well as what we are. He is the 2007 recipient of the Abraham Flexner Award for Distinguished Service to Medical Education.
You have said that you are very interested in the use of values as well as rules in guiding the behavior of physicians and teachers. How do you describe the difference between values and rules?
Values are enduring; rules are ephemeral. Justice (i.e., giving something its due) is a value. A principle deriving from this value might be: “Honor your father and mother.” Another rule deriving from the principle might be: “Call your mother every Sunday.” We tend to make idols out of rules, and to measure fidelity to the value by measuring: “Did you call your mother last Sunday?” Yet forcing the rule may, in fact, distort the value (we might be angry that we have to call, or become oblivious to the thousand other and better ways we can honor our parents).
Medicine is informed by a set of values that are enduring, that were present from Hippocrates onward. These include integrity, altruism and practical wisdom or prudence. Yet the rules in medicine have changed and are changing dramatically. When the forms of medicine and their attendant rules change, headlines are generated and resistance is provoked. The danger is that values will dribble away unnoticed in the noise of the debate about rules.
Distorted national conversations, such as we have had about healthcare reform, offer an example. In contrast to integrity, altruism and practical wisdom or prudence, the debates have been characterized by distortion of the truth, fear-mongering and concrete thinking far removed from practical wisdom.
Do you feel that an emphasis on, or even attention to, the issue of values (in a word, and fairly all-encompassing) was lacking in your own medical education? If you did, when did you become actively involved in remedying that—teaching who you are, as it were?
All higher education comes with a side effect. It carries the assumption that a thing can only be studied properly if it is treated as an object, as something held at arm’s length from the student. “Be objective” is the mantra of higher education. Subjective feelings are thought to be a source of bias and unreliability. In the case of medicine, however, good physicians are informed by the subjective. Respect for patients, deep empathy and compassion are all informed by truths revealed by the human heart.
I went to an enlightened medical school (the University of Rochester), one well-known for paying attention to the patient’s point of view. We were taught the classic values of medicine, and yet they meant little to me until I became a resident. I think that is because the journey to value-informed behavior is an inner journey; it begins deep inside each individual with value-laden imperatives (this far and no farther), and from there informs external behaviors. Residency is such an intense experience (it offers the steepest learning curve in medicine) that you not only learn medicine, you also learn about yourself and who you are, and you end up adopting a set of values to which you are faithful, as well as patterns of clinical behavior that make you effective.
Good physicians reflect on their practice. At the end of every day they ask themselves: “How good a job did I do in discerning and telling the truth?” “Did I put the patient’s interest ahead of my own?” “Did I do something creative today, something that harmonized the particular needs of the patient with the best generalizable scientific evidence at hand?” This daily habit makes the values real and defines who you are as a person and as a professional. It is a lifelong journey. It is never safe to say, “There, we have covered values, and now let’s move on to cover some other objective thing.”
What makes a physician an authentic practitioner?
The whole person shows up. I once thought I was going to win the New Yorker cartoon contest, a weekly event in which a cartoon is offered and the readers invited to submit a caption. This particular cartoon showed an executive sitting at a desk and having a conversation with a disembodied, but obviously living, head resting on his desk. The caption I submitted had the executive telling the head: “We find that things go better around here if the whole person shows up.” I did not win. The reason that the caption came easily to me is that in many work settings the intellect is invited and expected to show up, but the whole person may not be welcomed. Yet in medicine, patient care really is better if the whole doctor (or nurse, or other healthcare worker) shows up.
In addition to using the best science, those caring for patients should be compassionate. Compassion is different from sympathy. Sympathy says: “I’m sorry you hurt.” Compassion listens to the patient’s subjective feelings about being sick and acknowledges their authenticity. It offers companionship at the subjective level. Altruism and compassion are not techniques; they are new ways of being in the world. They require wholeness and integrity.
People come to doctors for three reasons: They have specialized knowledge (this feature is less important in the age of the Internet); they have experience and have reflected on their experience (“I’ve seen this before and this is what you do.”); and they have particular skills (surgical, prescribing, etc.). There is an additional reason, however, and one that is at the heart of the doctor-patient relationship: Doctors are human. Physicians and patients share a common human vulnerability; we are all going to suffer and die in the end. This shared vulnerability permits deeper conversations about suffering, conversations that require authenticity from both parties. Authentic physicians are easy to spot and are essential for good patient care.
If we accept the definition of chaordic as “harmonious coexistence displaying characteristics of chaos and order with neither behavior dominating,” how does it apply to medicine? How can chaos be beneficial, and can it coexist with the dictum to do no harm?
Dee Hock, the founding CEO of the Visa Corporation coined the term “chaordic” to describe complex organizations that function on the interface between chaos and order. The model is well-described in his book One from Many. Once you understand the model, you see it everywhere, especially in academic medicine and healthcare. Clarity of purpose, a few principles and a diverse group of people are needed for success rather than overly prescriptive rules of behavior.
While this model is designed to explain organizational behavior rather than doctor-patient relationships, it translates easily into safer healthcare. Some years ago,Ralph Stacey invited categorization of phenomena along two spectra: certainty and agreement. Certainty means that I have a deep understanding of the cause-and-effect relationships. If I take action X, result Y will certainly happen. Agreement means that experts all agree that this is the right step to take. Some illnesses fall into the category where there is a high degree of certainty and agreement. This is the world of clinical guidelines. If they are followed, healthcare will be safer.
Other times, however, the illness is more complex, and blindly following guidelines would make the care less safe. For example, if a patient has a simple community-acquired pneumonia, I should follow the well-established guidelines for treatment of community-acquired pneumonia. If, however, the patient has AIDS or is otherwise immunocompromised, and has multiple other diseases that will interact with both the pneumonia and its treatment, it would be dangerous to simply follow the guidelines. There is much less certainty about the results of treatment, and there is much less agreement about what to do. In that situation, a few simple rules and value-informed principles are better than rigid adherence to guidelines. This is the zone of complexity. There are also times when we have such little certainty and such little agreement that the illness falls into the zone of chaos. At that time, the best we can do is to look for emerging patterns that will help us gather data to enhance certainty, and to convene others and their observations to enhance agreement.
To accommodate the range of illnesses seen, healthcare institutions must be fluent in all three worlds: They must be vigilant about following guidelines where appropriate, and they must be able to manage complexity and chaos as needed. A Newtonian command-and-control organization is not flexible enough to accommodate this level of versatility. Healthcare organizations need to master command and control and chaordic techniques, and to know when to apply the different models.
Isn’t it difficult to teach “values”? Can you teach something like “honesty” or “virtue,” or any of those concepts that are usually their own reward, or is it a matter of connecting with something already inside a person? How do you persuade someone that values have a benefit, even it it’s only being able to live with yourself?
The best we can do is to create an ecology that supports life, an environment that nurtures the development of values. While the journey to authenticity is a deeply personal and largely interior journey, societal and institutional contexts are really important. Can a resident learn professional values in an institution that systematically demonstrates unprofessional behavior? Can we teach integrity, altruism and practical wisdom in a society that tolerates limited or no access to care for the uninsured and dramatically worse healthcare outcomes for the poor? All residents see the poor, and they know better than most the disparities in care. It is difficult to preach values when demonstrated behaviors are incongruous with the values preached. Nonetheless, I am hopeful. I am hopeful because the cause continues to attract good people and the goodness in people. Without ignoring the harsh facts, honesty also demands acknowledging the forces behind the facts and the large number of good people doing things to improve the situation. There are many stories of residents and others working around the broken system to do the right thing.
You have a wonderful e-mail address: Pilgrim. What does that mean to you?
We are all on a journey. Humans have three built-in faculties designed to guide our journey and to foster values: the intellect, whose object is truth; the will, whose object is goodness; and the imagination, whose object is beauty. Finding truth, goodness and beauty is a never-ending pilgrimage. I use the word “pilgrimage” to capture the directedness and sacredness of the journey. I hope that the email address reminds me and others of that journey.