Journal Set #1. Professionalism and Moral Defense… | by Jeff Woods | Nov, 2021

Jeff Woods

**Journal Series Intro: The following is part of a journaling project during my third year of medical school. This year is traditionally the first year med students start working with patients daily and is likely the most formative year of med school both professionally and personally. The content of these journal entries is my own experience and reflections at the given time in my training. Many of these thoughts have changed, or become more nuanced, since the time of their writing and were left intentionally raw.**

July 30, 2020 — Professionalism

The fellow later explained to me how there’s a new school of thought rising out of the younger generation of psychiatrists and their principles stand in direct conflict with the prior school of thought. As physicians it’s our moral duty to provide care to patients according to the highest of principles but it’s our professional duty to adhere to guidelines set by our predecessors/senior advisors/authorities. I find this dilemma fascinating. It largely signifies the issue I take with professionalism, it merely functions to perpetuate institutional norms. And people don’t like their norms changed so professionalism becomes a fortification against change, against innovation, against any evolution of the institution. Professionalism should allow people to perform their work at the highest moral principles even if that means challenging your authorities.

Professionalism tells us to be obedient to authority. Morality tells us to respectfully challenge orders we don’t agree with. Professionalism tells us to conform to pre-set standards. Morality tells us to evaluate those standards and push them to be better. Professionalism merely perpetuates old habits, morality improves them.

The more I think about the value in pursuing professionalism, the more I realize how short sighted and almost irrelevant that pursuit is. Everything that is actually valuable under the umbrella of professionalism is encompassed within the pursuit of morality. And by pursuing morality over professionalism, I gain the privilege of not inheriting the broken habits of the institution and I gain a clearer vision of how we might do things better.

I can dream all day about how I’ll do things better as an attending but I’m still left with a dilemma to deal with today. For the next ~7 years of training, how do I sustain moral patient care without the consequences of defying old professional standards?

[side note: Covid caused the school to discourage wearing white coats in patient care settings due to increased disease transmission caused by white coats. I have to ask, how long has the profession known that white coats increase transmission rates of diseases and STILL not abolished the practice of wearing them?! Professionalism says to wear a white coat, morality says to never wear them again.]

August 10, 2020 — Moral Defense Mechanisms

I couldn’t help but ask: “Given everything I know, would I be satisfied with that treatment plan if I was the patient?” And in this setting, my answer is “no” more often than not. But when I ask hypothetical questions about merely offering an option of therapy before jumping straight into medications with some gnarly side effects, I get struck with a whole diatribe about standard of care.

I heard something like “The patient meets all the diagnostic/prescription criteria and if you don’t recognize that, then you need to study more…” I had to really bite my tongue. I knew the patient met criteria and our plan was standard of care but I was trying to understand that pre-set standard and I thought our patient was the perfect springboard into a lively discussion over the pros and cons of therapy vs. medication and how standards of care are established in psychiatry. They probably gave me a “below pass” student eval that day and I certainly gave them a “below pass” educator eval that day; too bad educator evals don’t actually exist and my future is more dependent on their eval than their future is on my eval.

I tried to specifically frame my question in a non-threatening way but I still bet I got this reaction because the attending felt I was questioning their judgement. Which leads me to wonder what a student’s role is in promoting accountability in providing care at the highest ethical standard. Are students expected to simply observe the care administered or are they to get actively engaged with it? Ultimately I have to defer to the attending’s authority but when their decision is in conflict with my morals and I get ridiculed for asking a clarifying question then I feel powerless, left to watch the decision play out (perhaps poorly) for the patient. It’s almost like the student endures a moral injury by proxy of the attending. Within the safety of a classroom, it’s easy (and oftentimes fun) to disagree with a professor’s principles, but the dynamics of disagreeing change completely in a patient care setting.

The above scenario is no different than practicing physicians enduring a moral injury from systemic pressures to administer care that fails to satisfy their personal morals. This has me thinking it’s probably good to face the issue of moral injury early to build some “moral defense mechanisms” but I can see how easy it would be to merely habituate to moral injuries instead.

Moral defense mechanisms against moral injury… cool concept! I don’t want to habituate. I don’t want to feel guilt. Can I just forgive myself? Yeah, but how is repeated self-forgiveness any different from habituation? I think the difference is whether I accept the violation of my morals, perhaps I could forgive myself without accepting the moral injury? This would maintain the unacceptability of the moral injury while still engaging in self love.

Regardless, at the end of the day, my self-image depends on the morality of my work. I almost want to believe our brains have a way of taking inventory of the morality of all our work. And as we see in PTSD, a single immoral act can short circuit our self image and cause all kinds of mental illness. Perhaps, in these cases, the brain hyper-focuses on the immoral act and neglects to take a more broad inventory. I’d like to believe if the collection of our work/acts are categorized as varying intensities of moral and immoral with a neutral category at the center. Then a moral act would cancel out an immoral one of equal intensity.

This framework then postulates that as long as you do more moral work than immoral work, then your net effect on the world is positive and your self image can be preserved as an agent of good in the world. I think this is a very reasonable moral defense mechanism. If I’m coerced into a moral injury by the system or by proxy of some attending, this defense mechanism calls for me to focus on the immoral act in the context of my larger body of work. I only see this strategy going awry if we are continually forced to commit acts against our personal morals to the point of losing our moral context (i.e. the majority of our work becomes immoral); but at that point, lots of red flags should be raised, like it’s probably a good time to quit that job.

For now I take comfort in knowing I do moral work, I have a net positive effect on the world, my self-image is maintained, and I believe I’ve successfully staved off one of many moral injuries coming down the pipeline.

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