Stoic Medicine: A Guide to Rational and Ethical Practice by Vadim Korkhov

When I began embracing the philosophy of Stoicism two years ago, it came at a time in my life when I needed a way to deal with a myriad of issues facing my life that seemed too many to address all at once.  In applying this philosophy, I have realized its usefulness in application to the practice of medicine.  Stoicism has allowed me to be a more thoughtful, conscientious, and better skilled physician by putting the right priorities into perspective, and reminding me of my role in the process of a patient’s treatment.
It is altogether too easy to forget that my motivation is the patient’s best interest, and no one else’s.  While this may seem a natural conclusion, modern American medical practice is beset with distractions, such as financial performance benchmarks, impressing the patient in order to gain a favorable review, or dealing with political pressures within a healthcare organization.  Here, I hope to share some of the insights I’ve gained from Stoicism that I hope other physicians can use to improve their practices, and relieve from them needless burdens that they often impose on themselves by demanding of themselves more than what is possible or necessary.
I cannot deny that my background has greatly shaped my opinions and applications of Stoicism.  I am an intensivist, which is a physician that practices medicine in the Intensive Care Unit (ICU) of a hospital, where the critically ill are managed.  These are the sickest patients in a hospital who require constant and meticulous attention.  Patients admitted to the ICU have a diverse range of illnesses or injuries, or may require the ICU to manage after major surgery.  Some patients admitted to the ICU unfortunately are suffering terminal illness, and spend the last weeks of their lives in fruitless efforts to prolong death in the misguided hope of prolonging life.  
Critical care medicine requires a collaborative effort where the intensivist must rely on other physicians to complement his management in all but the most simple illnesses.  One would imagine that, in such a context, everyone would recognize an urgency to work together for the benefit of the patient.  And yet, over the years, this is not what I observed.  Instead, I discovered contentiousness between physicians, often to the point of pettiness over the most trivial matters.  I discovered politics earning greater place of consideration over a patient’s management than medicine.  I also discovered incompetence on the part of some doctors, which made it frustrating to be forced to work with them, as they often didn’t understand either what they were doing or what I was trying to do.  So frustrated was I at these impediments that I became bitter, and came to assume that when my plan was being thwarted, it was for personal reasons, slights against me!
Unless they leave the practice of clinical medicine altogether, and pursue research, administration, or academics, most physicians face problems like mine.  Like me, they face distractions to simply practicing medicine, as they learned in medical school and in their postgraduate training.  Medical training does not prepare them to deal with these issues, leaving it up to each individual to handle these problems for themselves.  Having no basis or preparation, they often succumb to maladaptive means, and due to the pressures of the career, have little time or energy to devote to correct them.  In this essay, I’ll share some insights I’ve had both in personal faults, but also in observing the faults of others.  In this way, I hope to be as comprehensive as I can of a wide range of experience, so that this advice can be applicable to all.

Stoic Medical Management: Applying Reason and the Right Use of Impressions, and the View to Providence

With all the pressure upon the physician to perform, medicine can be a stressful environment.  Besides the expectation of the patient to treat illness, there is also a pressure to treat quickly when the illness is severe and life-threatening.  Doctors, especially early in their careers when they have little experience, also worry whether they even have the skills to face the challenge of managing illness.  I myself remember those first few weeks at my first job, where I trembled wondering if I was going to be found out as a fraud because I might demonstrate too much hesitation in my decisions.  
It is thus easy to forget one’s faculty of reason in the face of stress, and resort to emotions as a substitute means for deduction.  Despite their training, doctors often do not apply what they were trained to do – to use deduction through objective evidence, arrive at a list of possibilities (differential diagnosis), and eliminate all possibilities until one of those possibilities is most likely.  Instead, they resort to instinct or gut feelings.  They “feel” that they know what the problem is and “know” the solution simply because their feelings confirm it.  
The ancient Stoics warned against succumbing to a false impression, and then acting too quickly on a whim.  Epictetus mentions it repeatedly in the Discourses, under many different conditions.  The excessive reliance on instinct over reason can lead to dangerous outcomes.  It can lead to the pursuit of unfounded suspicions while ignoring glaring problems.  Problems that are ignored often get worse over time, to the point where, once they are realized, become too late to correct.  
I can recall many cases where a doctor would forget to perform the physical examination — a basic tool of assessment.  Simply performing the physical examination saved hours of idle goose-chasing with pointless tests.  In another case, a physician consulted me for a patient who had shortness of breath, but never bothered to look at the chest x-ray he himself had ordered, which showed a glaring abnormality.  In another instance, a cardiologist was so perplexed by the nature of a patient’s heart disease that he simply walked away from the patient without doing anything at all.
Even early in my career, I recognized that the worst thing I could do was to panic.  As advised by the ancient philosophers, when you are overcome with a strong feeling – a passion – it is easy to succumb to a false impression about a subject.  The best thing to do is to do exactly the opposite of what many believe and not act quickly and rashly, but to pause for a moment to allow your passions to cool, and only then calmly assess the situation with the faculty of reason.  Then, it becomes far easier and clearer to pursue the correct course of action.  
Once you have repeated this process many times, it becomes ingrained as a habit, and less necessary to perform consciously.  This is ideally suited to medical practice, which is just a series of repeated presentations of mostly the same disease states in varied forms.  Without realizing it, I had acclimated myself to eliminating my passions by seeing the same thing over and over again, thereby gaining the proper use of impressions – those devoid of emotive pollution.  Such advice seems to run counter to medical glamor, which praises rapid decisions and remorseless confidence.  And some would prefer to be wrong and appear confident, than right and appear doubted.  
Exuberance of that kind has a tendency to lead to regret.  Once again, the ancient Stoics were right when they pointed out that acting out of passion inevitably leads to regret later.  By then, the faculty of reason has taken over in place of passion, and has discovered that earlier actions were foolhardy.  Seneca has a whole book about the dangers of anger, and how easily destructive it is, but it seems almost any passion shares this risk.  Many physicians have a tendency to retrospectively regret their actions after their heads have cooled.  They play Monday Morning Quarterback, wondering “if only I had done this… or that….”  It is easy to lapse into regret when a patient suffers a poor outcome.  I myself have not been immune to this.  Some patients simply do not fare well, even when managed entirely correctly.  In such circumstances, I have found it helpful to remember two things.  

1. There are some things that lie within our control and outside our control.  We can only discover things from sufficient information, without which we are powerless to arrive at any conclusion without guessing.  We also cannot treat every illness.  Some diseases have no treatments.
2. The Providence that everything eventually unfolds just as it was bound to unfold.  Some things are inevitable no matter what we do.  To the ancients, it was the Logos, which committed every action to the best course possible.  To us in the modern world, we must understand from science that there is a cause and effect to every event.    

By reminding myself periodically of these two factors, I can understand that my actions do not bear responsibility for absolutely everything that happens, and so I do not face regret.  I am then free of the burden of yet another passion, and so can pursue reason for the next task.  Even if I lapse in my judgement, or am simply incorrect in my conclusion within good judgement, it is better that I consider my error rationally, without regret, so I do not repeat it.  I still know that I did as much as my rational faculty was able.  I did not arrive to medical school knowing everything about medicine.  And I certainly have not learned everything about medicine since graduating from medical school.

Getting Along with Others: The Stoic Medical Community

In medical school, you are instructed to act as if you are the sole physician in the world, upon which everyone depends.  Every problem is up to you to solve, without counsel or support.  In the past, every physician was regarded as an independent practitioner, and his patients were his own as if they were his own children.  Nowadays, this is largely impossible.  There is too much to medicine for any one practitioner to know by himself, or to have skill in performing entirely on his own.  Therefore, the collaborative model of practice has emerged in recent years as the standard.  Where physicians in the past rarely had to work together, now they must work together to achieve even the minimum standard of care.  
At the beginning of my career, I was very frustrated by a lack of collaborative effort by other physicians.  My management was constantly second-guessed and scrutinized, and often not taken seriously.  Meanwhile, I felt that the older physicians were practicing poor and often outdated medicine.  There was always contention over who had the final say on a patient’s management decisions.  The older generation did not necessarily embrace the concept of collaboration, especially not with the young upstart they saw in me.  In truth, I was no less dismissive, as I also came to regard them with the same derision, just for different reasons.  In the end, it was the patients who suffered.  We, the physicians, only suffered our tender pride.  
There is a concept in Stoicism called “oikeiosis”, which can roughly be translated as “community.”  It is the idea that virtue is most useful when it involves society, and not just a single person.  Consideration for a virtuous act should follow what is best for everyone as a whole, and not what favors one or another.  In medicine, we are called upon for one chief aim – to better the patient.  Therefore, what is best for everyone involved in a patient’s care is what is best for the patient.  And what is best when many are involved, each of whom have the ability to make management decisions, is to work jointly so that the patient gains the greatest advantage from the expertise of all.  
Every doctor does for the patient what they believe to be right, but some may disagree with others on what that should be.  What always troubled me was when I judged a physician to be incompetent, and yet was forced to accept his plan, because he was the attending physician (the one who had traditional “ownership” of the patient as his own).  Sometimes, I would question, under my breath, the attending physician’s integrity, wondering if he was practicing for financial gain.  Instead of trying to reconcile with my rival for the sake of the patient, I’d ignore his plan, formulating my own, which would often be at odds with his.  It was a petty and sometimes passive-aggressive form of confrontation.  I was doing the same to them as they had done to me – dismissing them due to my perception of their incompetence.  Each time this would happen, nothing would be gained but bitterness on both sides.  
It is indeed true that some physicians are incompetent or worse, unscrupulous.  Some are outright fools, whereas others are ignorant, either willfully or accidentally.  Some may indeed be motivated by extraneous factors, such as money, pettiness, or pomposity.  But whatever their motivation, it is not always within my power to contend with everyone who crosses my path, since my proper goal is the care of the patient, not the education or morality of my colleagues.  My colleagues will have to fend for themselves in that.  Thus, I act within my power, limited such as it is, to act for the patient’s well-being.  
Whatever the disagreement is with another, regardless of the reasons for that disagreement, the situation remains the same.  Furthermore, my virtue has no bearing on the lack of virtue in others.  I would often seethe in anger that a colleague had ruined a patient with poor management, which I would then be forced to correct after the patient was handed over to my care.  As I came to realize my virtue was not affected by another’s vice, I ceased to be angry.  I could address the patient’s needs as I saw fit, doing as much as was within my power, now that the patient was mine.  Even if the patient was ruined later by another’s poor management, it was not up to me any more than my improvement of his care up to another.  
I tried many times to explain to colleagues why their actions were incorrect, but in retrospect, this probably sounded like a sermon more than a lesson.  The best way to teach someone the righteousness of your way was to live it, and demonstrate it with your own actions, because people learn best from example.  So I stopped going out of my way to teach, unless it was asked of me.  I concentrate on doing the best I can with the power and tools I’m given, without considering anyone else’s deficiency.  I follow, as a model, doctors that I’ve known whom I saw demonstrating exemplary skill and demeanor.  Now, people come to me to ask for guidance who would have ignored me in the past.  Perhaps, in time, others will take me as a model for proper decorum and skill.

Stoic Ethics: Care at the End of Life

It would seem that medicine would be a place where ethical concerns weigh strongly with every decision.  Medicine calls upon the physician to act always in the patient’s best interest, and so demand compassion and beneficence.  For most instances, it is clear what the physician’s duty is to the patient, when the goals of treatment are obvious.  And they are nearly always obvious because they are nearly always the same – to treat the patient’s disease without reservation.  At times, however, when goals of treatment are unclear, so are the ethical goals.
Patients enduring the end of their lives have different concerns than others.  Their conditions are no longer amenable to treatment, so that the ethical role of the physician is less clear than it would be if treatment had a clear path.  Patients usually are unaware of a terminal illness unless a physician apprises them, and so often rely on a physician’s counsel to make appropriate medical decisions.  Although it is a doctor’s responsibility to inform a patient when it is time for them to make plans for the end of their life, many do not do so, instead imposing their own brand of ethics upon the patient, without their consent, often without realizing it themselves.  They do this subtly, such as minimizing the severity of illness, or do not divulge options that the patients may have, such as hospice or other forms of limited care.  
It has seemed clear to me, in observation over the years, that their reluctance to raise these topics comes from their fear of their own personal mortality.  And if a physician cannot accept his own mortality, how can he discuss mortality dispassionately with anyone else about theirs?  Whatever the source of their reluctance, the doctor’s reluctance to discuss end-of-life gives the patient the impression that it is not worthy of consideration.  They are thus led on a futile path of treatment, while they suffer needlessly with pain, agony, and disability, until they finally mercifully perish.
Where there are problems in end-of-life care, it is usually because the patient with the terminal illness has goals of care that fly in the face of the severity of their illness, which causes prolonged hospitalizations through which patients suffer needlessly.  The confusion arises either because the patient, or their surrogate decision-maker, is ignorant about the advanced stage of disease (possibly because they have been steered wrong, as I mentioned earlier), or because the patient applies emotive reasoning to their decision, irrationally denying the illness.  Healthcare workers are then compelled to provide worthless “treatment” to such patients that they know will have no efficacy.  Thus, both patient and provider become demoralized.  
Patients at the end of life have the option to pursue palliative care.  They would be given medications to treat their pain and suffering, in place of definitive treatment for a disease state.  They would thus be free of suffering but, since their underlying disease is untreated, may also die sooner.  They may also die sooner due to the adverse effects of these same medications.  Unfortunately, because of the barriers mentioned, they do not do this until the very advanced stage of illness, often in the last days to weeks of life!  
The ICU is often the last place where such patients come to die, so that it often fell upon me to consider such weighty issues.  In time, I came to realize several principles that made my role less frustrating.  

1. I never pussyfoot around the issue of end-of-life or palliative care.  Many doctors are squeamish about it and so never bring it up, waiting for the surrogate to do their job for them.  Despite the grimness, families usually appreciate the honesty, and do not become angry, as many would believe.  I do this because I know that virtue is the most important thing to do, in Stoicism, and I am not dismayed if the families do not demonstrate the same level of virtue as I do, because their virtue is not my concern.
   
2. I recognize that I cannot change the opinions of others.  Most often, I must accept the decision of the family not to pursue palliation even when it is the right course of action.  I understand that it will ultimately be the patient who suffers for this, and not my frustration in dealing with it.  I will still be showing up to work no matter what the decision.
3. I recognize that, the majority of the time, families do come around and agree to palliative care.  They go through Kubler-Ross’ stages of grief eventually (denial, anger, bargaining, depression, acceptance), and will come to acceptance inevitably.  All I need do is wait.  

When it comes to discussions of terminal illness, the most important Stoic principle arises – the pursuit of virtue.  The cardinal virtues of courage and justice take a leading role here.  So when I have meetings with families to discuss end-of-life goals of care, I do it honestly and without fear.  I state quite plainly what condition the patient is in, what the options are and why the palliative option is the best option.  I do all this dispassionately, without affecting any air of false affection or friendship for a patient who is a stranger to me.  I leave the loving tenderness to the family.  I have found that honesty is greatly appreciated, and that some families will surprise you with their insights if they are offered the opportunity to separate their dramatic emotions from their reason by sitting calmly in a conference room.  
The practices of Stoicism have helped me to be a better physician by putting into perspective what are the most important principles that I should follow.  By adhering to Stoic ethics in pursuit of virtue, I can make a patient’s final days on this world be free of suffering.  By adhering to logic and providence, I can deduce appropriate medical decisions free of hesitation or guilt.  And through the understanding that I am part of a greater medical community, working towards common goals, however imperfectly they may be achieved, I understand my role in helping to foster a good working environment for all.  
 
Dr. Vadim Korkhov is a critical care physician who works in the ICU of a major urban hospital in the US.  He developed an interest in ancient Greece and Rome from an early age, and earned a BA in Classical Civilization from NYU.  He developed an interest in philosophy from a colleague, in more recent years, which led to his immersion in Stoicism.