Excuse Me, Doctor, What Exactly Do You Profess?

The late Edmund Pellegrino, M.D., revered medical educator, ethicist, and physician, often made the point that a professional professes something. Merriam-Webster  confirms that the etymology of the word, profession, includes the Latin for “public declaration.”

The Hippocratic Oath, probably penned by members of the Pythagorean sect, according to Ludwig Edelstein (see Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore: Johns Hopkins University Press, 1987), has for centuries been accepted as the gold standard for the practice of medicine. Nigel M. deS. Cameron (The New Medicine: Life and Death After Hippocrates. Chicago: Bioethics Press, 2001)
 explicates the Hippocratic Oath as containing four parts:

1.   Covenant with Apollo and others

2.   Duties to teacher

                            Regard teacher as equal to parent

                            Treat him as a partner in livelihood

                            Share money with him when needed

                            Consider his children as siblings

                            Teach medicine to own children, children of teacher, and pupils who take the oath

3.  Duties to patients

                            Use treatment to help the sick, never to injure or wrong them

                            Give no poison to anyone though asked to do so, nor suggest such a plan

                            Give no pessary to cause abortion

                            In purity and in holiness to guard the practitioner’s life and art

                            Use no knife on “sufferers from stone,” but allow others trained to do so

                            Enter houses to help the sick, not to participate in wrong doing or harm

                            Keep oneself from fornication with woman or man, slave or free

                            Not to divulge, but guard as holy secrets those things that are heard by the practitioner

4.  Sanction

Oath-taking by medical students has increased in the last 50 years, as reported by Neil Chesanow, in “Is it time to retire the Hippocratic Oath?” Medscape, 25 Jan 2017.  The form of oath taken by medical students has also changed. Many schools have re-written the oath in “updated” language, and a good number of students craft their own.

Do they swear not to have sex with their patients? Do the medical students or newly minted physicians now swear not to give poisons or pessaries? What oaths are taken in those states where physician-assisted suicide has been made legal? It would be good for the public to know. Perhaps it is time for physicians to post on their walls (actual and virtual) exactly what it is they profess to be and to do.

 

— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

 

Medical errors and more medical errors

Last week the BMJ reported that annually, there are 251,000 hospital deaths due to preventable medical errors in the US. There’s some debate about the calculations that they used to arrive at that number, and about what exactly constitutes a medical error. However, rather than quibble over the fine points, let’s acknowledge that medical errors are an ethical problem that must be addressed. In this post I would like to widen the conversation beyond the hospital walls. Below is a sample of some deaths due to preventable medical errors that weren’t included in the BMJ calculations (most of these ones happen outside of hospitals); nevertheless, they too affect thousands of people annually. I will also attempt to provide a taxonomy of the relevant errors.

Deaths due to the inability of the patient to obtain medical care because they couldn’t afford the care or the insurance — unknown number. The medical error here is a systemic one, the rationing of health care on the basis of who can pay for it.

Deaths of patients due to their being the subjects of human research — unknown number. This is peculiarly prevalent among embryonic patients (as Jon Holmlund wrote about last week). The medical errors include the failure to extend to embryonic research subjects the protections enumerated in the Declaration of Helsinki. There is also a category error: classifying embryonic patients as something other than human beings.

Deaths of embryonic or fetal patients through elective induced abortion — 977,000 (2014 data). The same category error as previous comes into play here: the failure to recognize the humanity of the unborn human.

Deaths of patients from drugs prescribed by their physician for the purpose of suicide — the numbers data is incomplete. The number is relatively low but projected to grow as more jurisdictions legalize physician-assisted suicide. The errors here include a professionalism lapse (forgetting that the professional status of medicine was established, among other things, on the dictum that doctors do not give deadly drugs, even if asked to do so). There is also the error of hubris: the belief that doctors can decide that someone should be allowed to kill themselves.

Preventable medical errors, all.

Seeing the Horror

A video released by The Center for Medical Progress (CMP)  about Planned Parenthood included these words: “Some viewers may find this content disturbing.” It was to warn the viewer about the images of piled fetal body parts dumped from a bag by an abortion clinic worker.

What might be most disturbing…and chilling…is not the body parts, but the casual and glib attitudes of the Planned Parenthood staff toward them.

A subsequent post  in the Bioethics Forum of The Hastings Center attempted to explain away this indifference:

…most of us also don’t want to see graphic photos of any other type of surgery either. But our desire to look away isn’t inconsistent with thankfulness for the life-saving and health-preserving results of any type of medical procedure. It just means we don’t want to watch their gory accomplishment. But physicians don’t have the privilege we have of enjoying medical results without seeing the unpleasant in-between.

I suspect that the author hasn’t watched all the videos. And I’m not sure what purpose bioethics institutes will serve for our society if they harbor notions that fetal vivisection is comparable to “enjoyable” medical results that are “life-saving and health preserving.”

Yes, as a physician, I can see body parts…and worse…without passing out. But every physician must recognize the moral significance of the connection to the human, or else the profession of medicine is not a moral endeavor. In contrast to attitudes of the abortion clinic workers, in the CMP’s videos, the former StemExpress employee Holly O’Donnell expresses a depth of moral insight to recognize that each of these aborted fetuses was more than just a “tissue opportunity.”

It had a face…I remember picking him up…he was big…I remember holding that fetus in my hands when everyone else was busy…It’s really hard knowing that you’re the only person who is ever going to hold that baby…I would think about things like that…I wonder at age 3 if she would like a color…or I wonder what it would look like, her mom or her dad…

Planned Parenthood’s brutality is the logical consequence of Dr. Alan Guttmacher’s (former president of Planned Parenthood) belief, subsequently effectively written into law by the Supreme Court, that “…no baby receives its full birthright unless it is born gleefully wanted by its parents.” Yes, Planned Parenthood and its supporters are being purely logical. But pure rationality in the face of human dismemberment is no virtue. Watching Planned Parenthood staff speak of selling fetal body parts, I am reminded of G. K. Chesterton’s words in Orthodoxy: “The madman is not the man who has lost his reason. The madman is the man who has lost everything except his reason.

The Physician’s Imprimatur

In a previous blog response about physician-assisted suicide (PAS), Mark McQuain asked, “Why involve physicians at all?” That question gets too little attention.

There are some easily discernible (and perhaps expressed) reasons why physicians are chosen to be the agents of assisting suicide. First, they have access to pain- or consciousness-relieving pharmacologic measures that also have the (in this case) desirable effect of stopping breathing when given in high enough doses. Second, by their professional ethic, physicians should approach patients with compassion, which, as mentioned previously, is the catchword that is quite deliberately attached to the act of assisting suicide by those who promote it.

But as Dr. McQuain suggests, access to painless methods for killing need not be restricted by to physicians, just as compassion is not; there is no law of physics that prevents others from assuming this role. To limit the methods and the responsibility to physicians is a willful act by society.

This leaves one main reason for committing the responsibility of assisting suicide to physicians: involvement of physicians gives it a much-desired moral certification, or imprimatur. Here is the logic, unspoken as it is:

  • Physicians have moral standing;
  • If physicians are involved,
  • Then the act has moral basis

But this gets it backwards. Physicians have moral standing based on what they do and what they refrain from doing. Edmund Pellegrino wrote often of the “intrinsic morality” of medicine which depended on the nature of the physician-patient relationship. Such morality stems as much from what is not done as from what is done.

We need not agree upon any particular bioethical issue to realize the significance of the tactic, in how it can could be used by proponents of various acts to enlist, and yes, even pressure or legally mandate, the involvement of physicians. Or, for that matter, the involvement other people whose life work is viewed by society as having moral standing.

If PAS were to be legal across the US, would physicians buy into the idea that it is consistent with the underlying ethic, or intrinsic morality, or their practice? I predict that most would not. Recall the vision of abortion (when first made legal by judicial decree) being done by the patient’s family physician, which presumed a longstanding benevolent and wise relationship. This of course failed to happen, and abortions have since become centered in facilities where patient and doctor remain, by no accident, strangers. Most physicians do not want to be associated with abortions ( and none of the many family physicians I’ve met) because they know that there is a quality to the act that impacts them; it would not be benign simply because they did it. And it is not consistent with the underlying moral and ethical basis for their medical practice.

So it will be with physician-assisted suicide. The strategic involvement of physicians will most certainly mean that some will be involved. But most who could be involved will decline, knowing, or at least sensing, the inverted logic behind how physicians got pulled into the affair to begin with.

Good Ethics Requires Bad News

Some bad news took me by surprise this week, taking the form of an article in the Annals of Family Medicine entitled, “Why Medical Schools Are Tolerant of Unethical Behavior.”  The authors described a medical school graduation ceremony in which the speaker thanked professors and healthcare professionals not just for competent and humane care, but for providing examples of “pure unethical behavior.”

I wondered if my surprise at these circumstances was a bit of bad news in itself. Either I was blessed to be away from such an environment, or ignorant of similar problems around me. To some relief I found (after looking quickly) that the authors were from Brazil, but a book by an American author is but the most recent reminder that the problem resides between our shores as well.

The authors themselves seemed surprised by the audience’s lack of unease or objection to the allegation, and concluded that the professional environment must be tolerant of the behaviors. They asked why, and described these possible reasons:

  1. Barriers to reporting, due to fear of retaliation, lack of anonymity, and complaining seen as a sign of weakness;
  2. Leaders turning a blind eye to problems;
  3. “Systemic disrespect,” that is, widespread problems of the healthcare system that produce long waiting times for patients, excessive staff workloads, and a culture where mistakes are not acknowledged and apologies not made;
  4. Lack of accountability by accrediting organizations for ethical behavior.

They go on to discuss conflicts between explicit and implicit values, with the implicit ones being “culturally appropriate” yet far from admitted publicly. Such conflicts produce a systemic delusion, as well as cynicism in the young and developing healthcare professional.

That such a situation exists merely highlights how critical the truth is to ethical behavior. Organizational dishonesty, in whatever form, corrodes the integrity of individuals and provides fertile ground for unethical behavior. Integrity requires a willingness both to hear bad news and to give it. Values greater than one’s personal image, comfort, or success must be paramount, or else bad news becomes a problem unto itself, as opposed to a useful and necessary tool for ferreting out problems and making organizations better.

We can’t find such integrity from purely utilitarian arguments. The authors cite, unfortunately, only utilitarian arguments for building a professional ethic (increased costs, medical errors, etc.), reminding me how the language of virtues has long ago faded from modern societies. They do note utilitarianism’s inadequacies in the problem of “administrative evil,” in which “standard operational procedures within an organization inflict harm or suffering on individuals by blindly following a cold bureaucratic rationality committed for the ends but not the means to those ends.”

It is virtue ethics that is required to fight the corrosive effect of pure utilitarian thinking, for it reminds us that one of the ends produced when disregarding means is that one becomes the sort of person who uses those means. This requires an understanding of virtues and the central nature of the character of man to any ethical system.

I am not confident that modern society is ready to recover the lost language of virtue. Virtue, it seems, must not be spoken of, lest the speaker be subject to the vitriol as experienced in the strident denunciations of Christianity we hear more and more about. To escape our mean state, however, we must venture to do so.

To discuss virtues, in turn, requires that we articulate a robust vision of the telos—the purpose and ends—of the practice of medicine. A description of a state of being greater than our common existence, greater than mathematical calculations of gains and losses, would give direction and meaning to our efforts. It would enable us to see beyond self-interest, to make the necessary sacrifices for the truth, to move ourselves and our organizations along the road to that greater goal. For such a journey, bad news becomes not an impenetrable wall or obstacle to avoid, but merely a stepping-stone.

Speaking about dignity

Several years ago, while on the verge of delivering the baby of a seventeen year old, I was taken aback by the number of friends that she had asked to accompany her at the event…an event formerly considered far more private than one in which fifteen or so friends might attend (it was a large delivery room). And speaking of private, the wording and location of her tattoo demonstrated further that private areas had lost their former distinction.

The only practical option at that time was to ignore the crowd and attend to the imminent delivery, and ensure the newborn’s and mother’s safety. I could only hope that everyone had the sense to stay out of the way if an emergency arose. There was no time for instructions, explanations, or crowd control.

All turned out well. The teenager delivered a healthy baby, and I stayed on duty on labor and delivery. Our paths never crossed again, but I have thought of that brief encounter many times over the ensuing years.

When I think of the struggle to protect human dignity from innumerable external onslaughts, I think of battles such as those over public policy, technology, and cultural trends. But what I have not seen well is how the struggle extends to the hospital bedside, when the most pressing threat is from the patient herself. How much ought we, as physicians, while comforting and testing and treating and advising, take a firm stand and square off with patients, to explain why they themselves are the biggest threat to their own dignity?

Such a stance doesn’t reconcile easily with the current notions of patient autonomy. A sense of patriarchy within the medical profession comes rushing back, and it would be foolish to claim that patriarchy was always done well.

I am hard pressed to think of examples of seeing a physician address such concerns, unless couched in biomedical terms. It is difficult to know which of the numerous behaviors a patient exhibits falls, ethically and practically, within the realm of the practice of medicine. What I can say, with the advantage of some years, is that with the transformation of medicine to an autonomy-centered realm, we have lost sight of the most important defender of each person’s human dignity: the person herself. If we are to claim our dedication to a patient’s dignity, then should we not be more willing to speak the truth about it—even if it shines a light on an area the patient would rather not be seen?

“Grace” as a principle for the medical profession

The other day I was speaking to another physician about grace. This was at church, not surprisingly, but later I wondered why such discussions don’t occur in the hospital. When I recall the more remarkable physician-patient encounters I have seen, the word that comes to mind as the common theme is grace.

We can see it in the physician calmly and pleasantly treating the irascible and demanding patient in the darkest, bone-wearying moments of a long shift. We can see it in the compassionate but direct explanation of the direst of news to a frightened patient. We can see it in the happy celebration of a beautiful newborn to a relieved and exhausted mother. And we can see it in the bedside comfort given to a dying patient in those quiet moments when time slows down.

If one agrees that grace exists, then he ought to ponder from where we get it. For me it is clear: grace is God’s gift of Himself to us. We can speak theologically about godliness, but grace is a more specific and tangible manifestation of what that is. In medical ethics we have the well-known and practical principles of beneficence, non-maleficence, justice, and autonomy. But these describe the nature of what we should do. It is time, I propose, to speak of what we should be.

If we don’t speak of such things, then we ought to hope that they are at least manifest in our comportment, words, and deeds. Yet in our postmodern age, when society has abandoned such discussions, the mere mention of grace, something deeply profound, might strike that raw nerve in every man that fires the memory of something far greater than we’ve actually become. Or for many, want to become. And if the field of medical ethics is to move beyond an artful sophistry that produces philosophical justifications for our basest needs; if the profession of medicine is going to regain the moral standing in society for which it was created, then our medical schools must teach the highest principles. Like the magnificent blessing of grace we have received, that speaks to more than the nature of our acts, but to the nature of our being.

Academic Medicine: In need of an examination?

Being a physician in an academic setting, my attention was drawn to this recent article in Academic Medicine: “Time Well Spent: The Association Between Time and Effort Allocation and Intent to Leave Among Clinical Faculty” by Pollart et al.

I had mixed gut reactions to this topic; ranging from the notion that this is an awesome topic long overdue for attention, to the questioning of why academia is spending its valuable time on such internally focused research.

But I found that there is a significant practical problem facing academic institutions that is driving this and similar research—the ongoing loss of experienced and capable faculty. What the study reports to have found is that the intent to leave an academic institution and academia in general was related mostly to the clinical staff’s impression as to whether the amount of time in a given area (clinical, research, teaching, administration) was too much or too little. The authors proposed that, “academic hospitals can work with individual faculty members to find the right mix of clinical, teaching and administrative responsibilities.” This seems simple enough, but do individual organizations have such flexibility? For example, very few said that they spent too much time in research (@ 1%); the dissatisfaction here was that too little time was spent. I suspect that the demands to produce revenue through clinical duties make it unlikely that all those desiring more time for research can be accommodated.

This first article then led me to a second in Academic Medicine, entitled “Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools,” by Pololi et al.

What was disturbing about the results was the authors’ “central and concerning finding…that faculty dissatisfaction was saliently associated with faculty members’ negative perceptions and distress 
about the nonrelational and ethical culture of the workplace.” The last thing the medical professional needs is such an environment in which medical students acquire their professional values. As the authors point out, “the detrimental culture for faculty members constitutes part of the hidden curriculum for medical students, who often become less altruistic and more cynical through the four years of medical school…” and that “if faculty project that the moral, ethical, professional, and humane values articulated in the formal curriculum are not reinforced in their own experience as faculty (through the medium of the hidden or informal curriculum), the goals of educating and graduating competent, professional, and humanistic physicians may be undermined.”

My academic setting is a smaller hospital and not the large university medical center and school setting, making it impossible for me to perceive the extent of the concerns; the article itself only highlights them, but does not help to clarify the scale of the problem. However, we ought to ask why there is such a questioning of the moral and ethical environment of medical schools, which are the formative environments of our medical profession. Perhaps the practical limits on advancement and the inherent competitive nature of large organizations (filled with driven professionals) prevent development of mutually supportive relationships. Perhaps it is but one manifestation of the consequences of the growth in cost of a highly complex medical system arising out of the advances in science and technology. Our capabilities exceed what we can pay for, and the institutional environment demonstrates the effects of the demands to produce something to justify the cost. Such demands can lead to ethical compromise.

I also wonder if ethical misdirections of our academic centers arise from a shrinking of the ethical foundation of medicine itself, to the narrow principle of autonomy. As the authors state, “[t]he scale of ethical/moral distress
 reflects reactions to the prevailing norms and possible erosion 
of professionalism and increased organizational self-interest.” If we have elevated autonomy to the highest principle, we should be unsurprised when self-interest begins to crowd out other professional motives.

An Ethics of Complexity

As a long-time member of the military medical community, this article caught my eye: “1 in 5 Army hospital leaders suspended in 2 years: What’s behind the discipline?”

The reasons for these suspensions are known only at the highest level of command, and I suspect that there they will remain. But such a circumstance is significant, and we must ask for the reasons, to determine if they are relevant to all of us in the healthcare profession, and not just to our military medical leaders.

In my decades-long experience with dozens of hospital commanders I have found that they are professionals of the highest integrity, dedication, and ability. They achieved their roles after years of challenging jobs, most certainly in the trying times since 9/11. They have ample leadership experience before being selected as hospital commanders, and the scrutiny and accountability they faced to get there is testimony to their abilities. It doesn’t take much of a slip to put one out of the running for hospital command.

But this level of scrutiny has become magnified in our age of technology and instant communications. Within large organizations vast amounts of information flow up and down the chain of command at the speed of light through fiber optic cables. Data is tracked, analyzed, and reported, requirements are created, and information is sought, gathered, pushed, scrutinized, speculated on, and multiplied. One effect is to have leaders constantly under surveillance, not from any mal intent, but from the pressures to succeed and avoid failure. When formerly errors might have been overlooked, found late, or simply not seen as errors, they now can be seen instantly and broadcast far and wide. If “to err is human,” there is diminishing room to be human.

In a small example–a few years ago I became the physician representative for my hospital’s implementation of an organization-wide initiative. The program was sound in concept, useful in practice, and beneficial to medical staff and patients alike.

The problem came as we watched the organization inch its way toward implementation. Nobody objected to the concept and it’s utility. Leaders and staff were simply too preoccupied with other demands. I as well did not pursue all the potential uses of the system simply because I already had my hands, and mind, fully occupied with everything else I had to know to practice medicine and use the existing computer systems.

I realized that if I, who am sought out as someone who can work through the complexities of technology, is at his limits in what he can attend to, then the organization is unlikely to get much more from either its busy leaders, or from physicians who have less patience or facility with the demands of technology.

I doubt that anyone can escape this phenomenon, for the complexity and scrutiny exist at any level, albeit in varying forms. We cannot afford to ignore it or simply acquiesce, for if the best among us fall, then the rest of are less likely to even try.

This steadily increasing complexity contrasts with a passage I recently re-read in Richard Swenson’s book, Letters to a Young Doctor: “There is no more beautiful sight in the world than that of a kindly, efficient doctor engaged in the examination of the body of a fellow human being.”

I wonder if such a passage makes sense to many people today. But what struck me is that part of the beauty was a simplicity unencumbered by the distractions of modernity. We decry “technology” but can’t separate ourselves from it. It’s not the technology itself from which we wish to be liberated, but the complexity that it brings.

What we need, then, is an “ethics of complexity” within the healthcare profession. This would measure the modern trends and pressures on and within healthcare by their tendency to create complexity, and thereby overburden and distract both healthcare professional and patient from the pure and ultimate goal of establishing a lasting therapeutic relationship, or covenant, as described by William May. The goal, then, of organizations, leaders, staff, and even patients, would be to identify complexity when it arises, and modify systems to mitigate it. I only hope that this one additional consideration doesn’t just add to the problem of managing healthcare.

An “ethics of complexity” would be grounded in the idea that mankind, in all his abilities to create and adapt, still has a limit…and that to push this limit is to begin to sacrifice something critical to our humanity. For those physicians who still sense the beauty of the doctor-patient relationship, such a recognition is overdue.

Lost Horizons

Having recently given two presentations on the nature of the physician-patient relationship, it seems only natural to follow in the footsteps of Jon Holmlund as he has been posting on the concept of professionalism.

As an instrument-rated pilot, I recently recognized an analogy between a training maneuver called “unusual attitudes” and the state of medicine today. Under normal flying circumstances, a plane is kept in straight and level flight by reference to the horizon. In situations where the horizon is obscured, one must learn to rely on their instrument panel. In this particular training maneuver, the instructor takes over the controls and confounds the middle ear of a “hooded” pilot through a series of steep turns, climbs, and dives. After adequately disorienting the pilot, the instructor puts the plane in a pre-spin or pre-stall attitude and returns the controls to the disoriented pilot with instructions to put the plane in straight and level flight with reference only to the instrument panel, not to the horizon. In today’s medical environment, physicians, too, have become disoriented by the commodification of the patient encounter and the medicalization of life. We have lost our horizon; we have lost sight of the fact that we are first of all healers.

What is meant by commodification? A commodity is an object for sale or valued for its usefulness to a consumer; and that usefulness and desirability are marketable. Furthermore, a commodity transaction is fungible: both the place and agent of transaction are interchangeable without detriment to the transaction, for the transaction entails no personal interest between buyer and seller apart from the product. Financial considerations govern the interaction.

This is part of the storm cloud that has obscured the medical horizon, disoriented the physicians, and put health care in an “unusual attitude.” And most of it can be traced to legal changes in the 1990’s which allowed “direct to ‘consumer’” advertising. When medical knowledge, products, and procedures become commodities, and when health care is viewed as a commodity transaction, physicians are impelled by financial incentives and disincentives to be purveyors of a commodity. They become moneymakers for themselves and money-savers for their employer or system. Suddenly, the patient and the healing relationship so vital to the medical encounter, has been lost from the horizon.

Furthermore, when health care is seen as a commodity, business ethics take precedence; and business ethics are not governed by beneficence, the principle that has historically governed medical ethics, but rather by non-maleficence. Merely avoiding harm creates a distinctly different timbre in the “transaction” than seeking the good of the patient. Moreover, like any business, medicine has become corporate- or investor-oriented, aimed at pleasing those outside the medical encounter, whether insurance companies or the government payors. The result is that the focus is now on outcomes, practicality, and the bottom line, all of which are easily quantifiable and controllable. The particular patient with their unquantifiable “contextualities” or peculiarities is again lost from the horizon.

But medicine is not a commodity; it is a relationship—not a fungible or interchangeable relationship with a provider or actor, but a relationship of trust between one who is vulnerable and ill and one who professes to be able to provide helping, healing, caring, and curing. As the late Dr Pellegrino has stated, medicine exists as medicine in the clinical encounter where medical knowledge is employed for the Good of the patient—to heal, cure, contain, or prevent human illness. This knowledge must be integrated into the life of the patient through the interpersonal relationship with the physician.

Is this concept of medicine as grounded in the personal encounter achievable or sustainable in today’s health care environment? I fear not. We have, indeed, been taken captive by outside interests, agencies, and agendas; we are no longer self-governing, but instead serve consumer demands and payor profits and interests. Young physicians entering practice have no knowledge of the historical horizon of health care founded on the “gift of hospitality” of religious orders, or of the physician-patient relationship of helping the vulnerable (rather than catering to the autonomous self). They have been deprived of their instruments and are oriented solely to forward progress with no inclination to consider the shoulders on which they stand. They have been nurtured on the sour milk of the “medical-industrial complex” and are flying upside down–they are disoriented and don’t even know it. And those older physicians who, despite loss of the horizon, can rely on their instruments to maintain straight and level flight, are landing and walking away from the storm–prudently, some might add.

I do often wonder whether I am clinging erroneously to an idealized version of the past when I should be riding the edge of the coin (as I mentioned in my last post). Is it possible to ride the edge of this coin maintaining a hold on the good of the traditional understanding of medicine while moving forward in a new paradigm? Or have we already advanced too far into the storm cloud, deprived of the necessary instruments, to even catch a glimpse of horizon much less an adequate grasp of it, one that would enable us to right the plane before it is too late? Can we ever again be first of all healers?