Another important but under-recognized determinant of our well-being is our personal philosophy—the deeply held beliefs and values that address the most fundamental questions of our lives: the meaning and purpose of life, death, joy, and suffering; why things happen the way they do; the nature of our relationship to other people and to the world; and the nature of our goals and responsibilities as human beings. Our personal philosophies define our expectations of ourselves and other people. They guide the way we perceive and respond to our world and help us identify our place in it. They define the framework by which we imbue things in our lives with meaning, joy, or pain and by which we determine what seems right and what seems wrong.
Developing a personal philosophy tends to be a subliminal process—a gradual internalization of attitudes and values from family, culture, education, and life experience. This process makes it possible for us to be entirely unaware of our core beliefs as an ideology; we may take them so completely for granted that they just seem to be part of the way things are. If we do not understand how these beliefs filter our perceptions and shape our behaviors, then we are unable to subject them to critical reflection and to decide which parts work well for us and which parts need to be changed.
An aspect of personal philosophy with special importance to clinical practice is our attitude toward control. Through the influence of Western culture in general and medical culture in particular, we often perceive being in control (of diseases, patients, and the health care team) to be the ideal state (Table 6-1). We use specific intellectual tools for gathering and applying knowledge: reductionism—“Sickle cell anemia is attributable to the substitution of a single nucleotide;” linear causality— “A causes B;” and generalization— “Asthma responds to bronchodilators.” All have a distinctly controlling, outcome-oriented focus, that is, to manipulate A so as to control B. Although this approach has led to important technological advances, it also has important adverse consequences.
Table 6-1.A comparison of control- and relationship-based personal philosophies. ||Download (.pdf) Table 6-1. A comparison of control- and relationship-based personal philosophies.
|Attribute ||Control ||Relational (I–Thou)* |
|Phenomenon of interest ||Thing-in-itself ||Thing-in-context |
|Epistemologic strategy ||Reductionist; linear causality ||Emergent; systems model |
|Clinician’s stance ||Detached observer ||Participant observer |
|Information deemed relevant ||Objective data only ||Subjective and objective data |
|Model for patient–clinician relationship ||Hierarchy ||Partnership |
|Focus of attention ||Outcome-oriented ||Process-oriented |
The control model creates unrealistic expectations that limit our opportunities to feel successful. Consider, for instance, how our expectations of good control in caring for a diabetic patient allow us to feel successful only when the blood sugar is tightly regulated. The patient’s blood sugar, however, is influenced by many factors over which we have no control, the patient’s own behavior being foremost among them. We become angry at the patient whose noncompliance stands in the way of our success. If success for us is defined only in terms of controlling disease, we are precluded from feeling successful in many, if not most, situations. Accepting responsibility for outcomes over which we have little or no control is highly stressful and leads us to feel helpless, anxious, and angry.
Our quest for control also creates distance and detachment in the patient–clinician relationship, which, as we have already seen, is an important factor in professional satisfaction. A strong orientation toward control leads to hierarchic relationships. This, coupled with the reductionism and labeling inherent in medical thinking, turns patients into objects, and we find ourselves working more with things—organs, diseases, medications, and tests—than with people. We, too, become depersonalized in this process, leaving no room for our own subjective experience.
An alternative philosophy that avoids many of these problems emphasizes relatedness rather than control. This model does not reject the insights of reductionism, but rather builds on them by adding an appreciation of context and relationship. Therefore, although A may seem to cause B, there are also other mediating factors and bidirectional interactions (A and B influence each other). For example, the tubercle bacillus causes tuberculosis, but not everyone who is exposed to this bacterium becomes ill; environmental and socioeconomic factors also contribute to the process. The illness, in turn, affects those contextual factors; no portion of the system exists in isolation.
In the relational model, we seek to be with and to understand the patient in a number of dimensions simultaneously—biological, experiential, functional, and spiritual. As we come to understand patients’ experiences, we may or may not identify opportunities to recommend strategies or undertake treatments to ameliorate their suffering. We are mindful that patients are ultimately responsible for their own lives; they may or may not accept our suggestions. In some cases, we may have no suggestions or treatment to offer, but we can still find success in offering, in the words of Arthur Kleinman, “empathic witnessing,” honoring the patient’s need for connection—a healing intervention in its own right.
This relational model helps us avoid unrealistic expectations of ourselves. It offers us the opportunity to feel successful in situations, such as untreatable illness or a patient’s refusal to accept our good advice that would seem like failures under the control model. The relational model also leads us to more effective action. In contrast to the control model, which attends exclusively to outcomes, this model calls for explicit attention to process, to the quality of communication, and to the values enacted in the way we work together. Paradoxically, it is by letting go of outcomes and focusing more on making the process as good as possible that we achieve the best outcomes. The relational model also gives us more room to look outside ourselves for guidance and solutions—and to admit our own limitations or powerlessness.
Whereas the control model creates barriers between clinicians and patients, the relational model keeps us closer to the experience of both our patients and ourselves, thereby increasing the opportunities for our work to be meaningful and decreasing the potential for frustration, alienation, and burnout.