Autonomy of a Different Kind

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says ‘Morning, boys. How’s the water?’ And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”

― David Foster Wallace, This Is Water

One of the many essays I wrote in applying to medical school was in response to the question, “is the medical profession unique?” My response rejected the notion that medicine is somehow unique, wary of the implication of self-importance contained within the word “unique” and hesitant to uphold the suggestion that doctors possess any intrinsically exceptional qualities. After all, experience has shown me that the qualities of compassion, intelligence, skill, and focus—so often lauded as essential to medicine—can be found in many other professions.

Indeed, many of the aspects of the medical field once heralded as evidence of medicine’s singularity have long since begun to disappear. For example, many current practitioners would have us believe medicine has begun to decline as the autonomy once enjoyed by small, independent practices is replaced with treatment pathways and standardization.

So then what continues to drive us to the practice of medicine? As Daniel Pink explains in his book, Drive: The surprising Truth about What Motivates Us, human motivation can be broken down into three essential elements: autonomy, mastery, and purpose. While it is not difficult to see how the practice of medicine can fulfill our intrinsic need for mastery and purpose, the perceived loss of something as basic as autonomy is distressing. However, my experience on clerkships so far has forced me to reexamine both my response to the question of medicine’s distinctiveness as well as the role of autonomy in medicine. While I maintain that there exists nothing particularly distinctive about physicians in and of themselves, I’m seeing that the nature of practicing medicine holds something that distinguishes it from other professions, and an autonomy of a different kind.

Nowhere has this been made clearer to me than during my family-centered care home visit during my pediatrics rotation. As part of the rotation, students are paired with a family from the Vermont Family Network—a statewide organization providing support to families with children born prematurely or who have chronic illnesses—and given the opportunity to learn from these families in a non-clinical setting. Emily welcomed me into her home and shared with me her life story, including the challenges that came with raising a child with Duchenne’s muscular dystrophy. Devan, in turn, shared how living with Duchenne’s had been a struggle for him. We sat and chatted about lacrosse, summer camp, the FDA, and our mutual experience living in Washington State. They offered me more than a glimpse into the little joys that make their family whole but also showed me something of the pain that comes with living with a debilitating, degenerative disease. I was privileged to have been shown so much.

I’ve found that my third year has been riddled with these windows into the lives of other people—so much so that it’s become increasingly easy to take this unique aspect of our trade for granted. As the epigraph above alludes to, while so much of our education can teach us how to think, we must teach ourselves how to be aware. I know that I suffer from lapses in awareness: when saying goodbye to Devan I reached my hand out to him, neglecting to realize that his condition precluded him from lifting his hand to meet my own. I had spent almost two hours with this young man and not once realized that he never reached up to bat the flies from his face. Swimming along, I had failed to see the water around me.

This interaction with Devan prompted me to consider what else I have missed in speaking with patients and their families. As a medical student, I am so focused on developing an agenda, and though that agenda may be patient centered, that does not always mean my attitude is as well. In this way, I realize, while the components of patient centered care as we have been taught may be rehearsed, the awareness it takes to achieve a truly patient centered mind-set must be consciously practiced.

These little windows into the lives of others are what makes medicine unique, and they are a thing to be treasured. As Wallace writes, “The really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able truly to care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day.” Therefore, by exercising awareness in the practice of medicine, we may achieve the trifecta of human motivation according to Pink: we find purpose in our sacrifices to our patients, mastery in the care we provide them, and autonomy in the choice we make to place the patient first.