Searching for the Why: Introducing the Hippocratic Forum

This is a question frequently posed to aspiring physicians during medical school interviews, as we each discovered at the beginning of our journeys as current physician trainees. Like most of our peers, we discussed our desires to pursue a vocation in which we could take care of fellow suffering humans while also engaging in deeply rewarding intellectual work. However, over the past decade or so, as each of our training paths has unfolded, the emphasis on this question has changed.

Today, many young, bright, diligent students are asked, often by doctors themselves, “Why do you want to be a doctor?” Genuine interest in aspiring physicians’ motivations has been replaced by a sense of incredulity—even implicit dissuasion. What accounts for this change?

By now, the “burnout epidemic” plaguing contemporary medicine has been well-characterized. While the term “burnout” may be both hackneyed and non-specific, there is no denying the fact that something about medical training and practice leads to high rates of practitioner dissatisfaction, depression, anxiety, substance abuse, and—in the worst cases—suicide. Moreover, recent findings have suggested that burnout occurs much earlier in medical training than was previously thought. High rates of resident and medical student burnout have been noted, leading to both a greater awareness in medical schools and increased attention to preventive measures for residents and students alike.

And yet, despite identification of the harmful consequences of burned-out trainees, efforts to improve these outcomes have repeatedly fallen short. Initiatives focusing on venting sessions, yoga, free meals, pet therapy, and medical student professionalism courses consistently fail to protect trainees from a training process that leaves them vulnerable to moral malformation. Perhaps more importantly, these interventions fail to inspire trainees to answer that question—“Why do you want to be a doctor?”—with clarity and conviction.

It is a basic tenet of medicine that if treatment regimens consistently fail to bring about an expected return to health, then the initial diagnosis must be reconsidered. As current trainees, we submit that those within (and increasingly outside) medical practice have failed to accurately diagnose what ails contemporary medicine. It is not merely long hours, caring for critically ill patients, or operating on minimal sleep that wears trainees down. Nor is it solely the result of increased bureaucratic expectations, excessive amounts of paperwork, or an ever-expanding expectation of non-clinical responsibilities. Rather, the problem lies much deeper, at the core of what medicine itself is and thus what a doctor himself does.

The Diagnosis: What Really Ails Modern Medicine

While we were all asked why we wanted to become doctors, none of us at any point in medical training were ever asked these fundamental questions: “What is medicine? What is medicine for? What does a doctor do?” These questions deal with the nature and purpose of medicine, and how a physician responds to them determines how she will then practice. They are teleological and potentially normative, setting the implicit standard for how medical trainees behave and act now and later as practicing physicians. Yet, in the medical mind, these questions are seen as irrelevant or at least somewhat deviant from the “high-yield” medical education process that seeks to produce competent, compliant, efficient doctors. Nevertheless, it seems self-evident to us that these questions are central to what it means to flourish as a physician.

While the historical understanding sees medicine as an intrinsically moral practice, that understanding has become increasingly eclipsed today. Medicine today is often described in transactional or industrial terms, portraying physicians as “providers” and patients as “consumers.” In places where this transactional framing is less apparent—such as when patients experience critical illness—physicians are often encouraged to think of themselves as technicians who are trained to bring about an expected product of solved clinical problems.

Yet when trainees engage in work they initially held in such high moral regard, only to find the labor increasingly depersonalized or bureaucratic, they lose morale, becoming literally “de-moralized”—experiencing both ethical erosion and a sense of helplessness to mitigate this.  When trainees who hold the traditional covenantal understanding of the patient-physician relationship as normative increasingly find that structural realities preclude meaningful time with patients, they experience a lack of fulfillment at the core of their work. The vocation itself becomes difficult to justify. Answers to “Why?” and “Why a doctor?” become so difficult to articulate that many trainees simply give up asking them, embracing the modern mantra of today’s total work culture: “Just do your job.”

The clinician and Holocaust survivor Viktor Frankl famously draws on Nietzsche in his book Man’s Search for Meaning, to argue that the man who has a why can bear almost any how. Both the ancients and more contemporary moral philosophers would not be surprised at the sense of dissonance trainees experience as moral agents in settings where the nature and purpose of their work feel foreign. They have lost their why, and thus the how of doctoring can feel like going through the motions as so many cogs in a medical machine.

If medicine is about the pursuit of patient health and physicians are understood as moral agents engaged in a fiduciary partnership—what we might even claim as a “moral friendship” with patients—it is little surprise that current trainees will experience a deep sense of something missing. Data on the so-called “hidden curriculum” in medicine provide empirical evidence of how this moral degradation process can play out over the course of one’s medical training.

The Prescription: The Hippocratic Forum

In the face of these challenge, what hope do trainees have to rediscover meaning and purpose in their work and avoid the pitfalls inherent in training? Contrary to the ethic of independent self-help and wellness that contemporary medical training has instilled in the face of burnout and bureaucratization, we argue that hope of recovery lies not in the individual trainee’s own ingenuity, diligence, or yoga practice, but in the outside testimony of others. What is lacking in modern medical training is a community of fellow trainees collectively committed to a rich, morally robust view of medicine and the physician’s place in it. Rather than speaking about the purely theoretical aspect of what medicine is, trainees need a practical approach to implementing and re-envisioning those values that brought them to medicine in the first place. They need support as they work on growing in those ideals through the ordinary circumstances that come with each patient encounter.

This is the purpose of The Hippocratic Forum. There, we seek to provide medical doctors and trainees the tools to aim for higher ideals, form meaningful relationships, develop cognitive strategies to persist in the face of structural challenges in training, and find space for mindful reflection in the midst of the challenges of contemporary medicine. We do this through brief, digestible podcasts (with an average length of ten minutes), compelling written work from fellow trainees, and an intentional community of medical trainees who support one another in their vocational growth.

We recognize that the format of the Forum is hardly novel—there are innumerable medical podcasts, online journals, and blogs already trying to enhance medical trainee resilience. Yet we believe the Hippocratic Forum offers something new in its pursuit to home in on the core of the problem—in medical parlance, to tease out the etiology, and not merely the symptoms of what ails so many trainees. The Forum aims to escape the post hoc approach of many burnout interventions in medicine, which equip medical trainees with resources they simply don’t have the time or energy to use.

Instead, the Forum aims for something more like a “replanting” in a moral soil of questioning, reflection, and redirection. More than this, we want to explore how cognitive practices like mindfulness and conscious reframing can be harnessed to lend greater clarity to the moral nature of our work and its attendant challenges. And we intend to create a community in which friendships can be fostered with the core belief that we need not work in isolation, that only in sharing the joys and burdens of one another can we also offer the best to our patients who are suffering and afraid.

Instead of merely bemoaning the broken parts of contemporary medical training, our focus is to consistently draw on and highlight moments of beauty in medicine, where fellow trainees find themselves returning to the roots of their work. We also recognize that in seeking the moral ideal, we need a consistent posture of humility and patience. The healing of medical training amid the burnout generation will involve small changes in perception and the trajectory of lives—changes so small that it may appear that nothing has taken place. But this is where all such reform begins.

Sharing Our Stories

Like all humans, physicians are narrative beings. We are reminded of the good moral work before us by sharing stories, raising questions, and pushing one another to go deeper and find the why. We do this in clinical problem-solving all the time, with ferocity and persistence; why not do it with regard to our vocations? Discussions of virtue, attention to the humanistic element of medicine, and acknowledgment of the centrality of faith and other moral communities is integral to the project of the Hippocratic Forum. Rather than shy away from questions of teleology or moral norms amid a training culture that often pursues a least common moral denominator, we embrace such questions, recognizing that true moral diversity and open pluralism offer both hope and opportunity to learn from others.

Crucially, the Forum will function as a collaborative moral project for trainees and by trainees, not more instruction from experienced educators. At its best, we hope it will fill an urgent need for trainees concerned with questions of ultimate import who may feel too fatigued, confused, or cynical to broach these in the classroom and on the wards—who are tired of reading soft-soap reflections on wellness that reduce all solutions to sleep hygiene and reflection exercises. We want something thicker, more practical, and alive. We hope the Forum might provide a thoughtful, diverse, and compelling answer to those questions faced both by aspiring physicians in their interviews and by trainees on a daily basis.

Why it is that we engage in this good work?

Why do you want to be a doctor?