Humility and Medicine, Lessons Learned: Perhaps the Fifth Ethics Principle

There are many qualities necessary to be an effective and compassionate physician. In the modern era, much of medical education focuses on the complex pathophysiology of disease and clinical presentation. This is the current challenge of the necessary investigations and therapeutic interventions. What I have learned after almost 50 years of practice is that a hefty dose of humility is necessary to complete the prescription for humane and empathetic medicine. As well, for physicians, the principles of medical ethics are very important, and perhaps humility should be added as the fifth principle to the traditional four principles of autonomy, beneficence, non-maleficence, and justice.

I recall vividly how Dr. William Walker, the physician who was one of my teachers in Dundee who moved to Aberdeen, where I followed him for a house job (internship) communicated to the head nurse (sister) who joined us on ward rounds. When a suggestion as to a treatment or investigation was expressed, he invariably would turn to her and say, “what do you think sister (term for head nurse)?” If she had any reservation, he would consider it carefully before planning. My other great model was Dr., Barnard Berris, whose chief resident I became in 1974 at Toronto's Mt. Sinai Hospital. When a politician patient was being seen by him with his team which included me and an intern the patient remarked that he only wanted Dr. Berris and none of the “students”. Berris replied, “In this teaching hospital, the only way you can see me is with them. That is how I learned to be a doctor and now it is my duty to help train them to be good doctors as well.” That was the end of that conversation.

While working at a memory clinic, I saw an 83-year-old gentleman with a chief complaint of decreased recall and a tendency to repeat himself. He was still working as the director of a large and successful construction company. He was independent in his activities of daily living. He scored 22/30 on his MOCA (Montreal Cognitive Assessment), with demonstrated problems in recall and in the Trails B part of the examination, but otherwise he performed well. [1] His MRI revealed atrophy and microangiopathy. I was concerned about whether he might be a candidate for Donepezil therapy and was concerned about his driving. I explained to him the MOT (Ministry of Transport) reporting requirements and the risk of insurance problems should he have an accident and the insurer questioning why he was still driving. With a modicum of resistance, he agreed to take the on-road driving assessment but turned down the cholinesterase inhibitor. Several months later he passed the driving test and was pleased but still had memory problems.

He sold his company but remained on the board of directors and on the board of his condominium. His family wished for another opinion, and he saw a behavioral neurologist (I am a geriatrician) who sent him for another driving test and told him and his family that he had dementia of the Alzheimer's type. After discussion with his family, he asked to have me see him again. In the meanwhile, he passed his second driving test. He once again refused to take the medication but was paying better attention to his lifestyle, including discontinuing all alcohol intake, which was quite substantial and well over the newly recommended amounts by the Canadian Centre on Substance and Addiction.

He indicated that when the appointment was made, he did not want to do the MOCA again as it made him “nervous.” He was very lucid at the interview and could relate to me details of both his board meetings and the items discussed and their resolutions. He had resumed driving with no problems. I requested that considering the second opinion and my finding of very good function on the current interview that he undertake the MOCA again. It was done, and he scored much better than my previous testing. I did not have a record of his score at the office of the other doctor. His score at the office I was working at was:

Cognitive Assessment

@MOCA: 25/30 V8.3 (up 3 pts)

@RECALL: 2/5 (up 2 pts)

@CDT: 3/3 (no change)

@BNT: 14/15 (up 1 pt)

I was very pleasantly surprised. I said to him and his wife that I could not clearly explain the course of his condition and his improvement in his MOCA other than his discontinuation of alcohol and a major decrease in stress when he retired from being CEO of his company. I also explained to him and his wife that if for example, had he decided to take the medication, the conclusion of the improvement of his MOCA would likely be attributed to the medication. I gave him anecdotes from my years of practice where improvement in a medical condition was attributed to some intervention that, in fact was never implemented, such as a medication.

Humility is one of the important qualities that a competent physician must have. There is a tendency that as one becomes more seasoned and adept at your profession you feel more confident in your assessments, decisions, and discussions. I recall some of the great physicians that taught me express to patients' anecdotes to help them come to a correct decision about a medical treatment. It helps to have a sense of humor and respect for the patients' cultural reference points rather than just relying on medical “facts.” I recall the challenge of convincing a very capable 82-year-old retired salesman that he agree to the insertion of a pacemaker after he had a number of serious blackouts. Explaining how the pacemaker worked did not convince him. Having a female neighbor of his living in the same retirement home who had a pacemaker successfully inserted did not work. Not even after she grabbed his hand and applied it just above her left breast with the words, “see Sam it's nothing”. It was only after I made the analogy of what he would do if the battery on his much beloved Oldsmobile failed. “Would you throw the car away Sam?” “That would be stupid, it's still a good car, it just needs a new battery.!” “Exactly!” I said, and 2 weeks later he received a new 10 year expected life-span pacemaker.

As a physician and everyone I can think of must have a modicum of humility which is sometimes difficult to maintain especially as you move up the practice and/or academic medical ladder. In the culture of medicine, it is normal for patients to question a physician's reasoning and common to request a second opinion or quote from an internet search about what the patient discovered about the disorder in question. Physicians should learn to accept such questioning in good faith and not become defensive, with responses, “would you prefer to be cared for by Dr. Google, or me?” I try to take a different approach. If I am going to recommend an intervention, I ask the patient or more often the accompanying family member to look up on their smart phone the name of the medication and we read the text together. I then can have a mutually respectful discussion about the pros and cons of such an option for care.

Maintaining a modicum of humility is a vital component of providing quality care. It spans more than medicine. Accordingly in addition to recognizing your talents does not mean believing they are limitless. “Accepting your strengths doesn't lead to pride, but instead to humility; you're less likely to resent what others have if you understand your own bounty.” (Gina Barreca: novelist and author) [2] and “Life is a long lesson in humility,” James M. Barrie (author of Peter Pan) [3].

In addition, we as physicians must understand the benefits and risks of the investigations that we use to evaluate patients, especially those with cognitive problems. Labeling someone with the term “Dementia, or Alzheimer's Disease” can have a devastating effect on their sense of self-worth or concern about their future health and well-being. The family must cope as well as the prospect of care needs can appear insurmountable. How does one internalize the concept of humility as a physician. It may be a characteristic that is part of that person's make-up. For me it was watching and learning from truly outstanding medical teachers who demonstrated humility in their manner by which they interacted with their patients and their trainees and other health care staff.

When I decided to study medical ethics, one of the lessons I learned was to try and adhere to the basic principles which included beneficence, autonomy, non-maleficence, and justice. Humility is not mentioned, but it should be perhaps as number five, as without it, physicians may not be as able to follow the other four pillars of ethical decision-making.

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