The Virtue of Hope in Medical Training

Abstract

While many of the challenges of contemporary medical training are characterized uniformly as “burnout,” such a diagnosis is nonspecific and overlooks the degree to which the flourishing of medical practitioners depends on the development and exercise of virtue. The virtue of hope, in particular, is indispensable to sound medical practice generally and the flourishing of trainees. It is only through sound apprehension of the nature of the virtue of hope, the challenges to the cultivation of hope that residency poses, and practices that allow such cultivation, that contemporary trainees can learn to care well for patients and flourish in their own right.

Summary:

While the general term “burnout” is used to describe many of the challenges of contemporary medical training, a more precise characterization that unifies these challenges is a deficiency of the virtue of hope. Medical trainees face many obstacles to the cultivation of hope during training, but learning both to correctly identify this deficiency, and practices which prove a fitting response, offers a way forward.

Confidence and hope do more good than physic.

Galen, second century (Bryan 2007, 212)

Hope is easy for the foolish, but hard for the wise. Everyone can lose himself into foolish hope, but genuine hope is something rare and great.

Paul Tillich (Tillich 1990, 1065)

It’s 5:20 a.m. and you are the overnight admitting resident. It’s been a taxing night, your sixth in a row, but the 5:30 cutoff is coming soon, and you’ve managed to come up with sufficient plans to ensure the safety of the patients you’ve admitted so far. You feel the effects of six straight nights in every organ system: the constant, low-level headache, the dry mouth, and the growling stomach. Your eyes blur as you scroll down the computer screen, praying you be spared a final admission which will easily add an extra hour to your shift. All you want is to go home to your apartment (currently in disarray), eat a small meal, shower, and see how much you can catch up on your sleep debt before returning for another shift.

But then it happens. The gnawing alarm of your pager at your side causes your stomach to drop. You curse silently under your breath—an admission at 5:25. There’s no use in fighting it, you’ve tried that before; it will only delay the inevitable. Hopefully, this is an easy one. You pull up the chart and slump back in your chair. It’s Mr. Jones, a patient well-known to you. He is a sixty-five-year-old with heart failure, obesity, chronic obstructive pulmonary disease, narcotic dependence—the problem list is long. In your less proud moments you have described him as “hopeless”—a patient who frequents the ED and is always admitted. Those caring for him rarely make any progress on his underlying conditions and he often leaves against medical advice, only to be readmitted again in the coming weeks.

Body and mind exhausted, you pick up your stethoscope and head for the ED.

Hope among a Generation of Hopelessness

While the above vignette may seem fictionalized, it is likely one of the most ubiquitous experiences shared by medical trainees—a routine instance both leading to and symptomatic of the now-household term “burnout” (Peterson 2019).

But when we invoke burnout, we ought to be more specific (Dean, Talbot, and Caplan 2020, 923). What if what marks this instance is not only the routine existential exhaustion that comes with modern medical training but rather the absence of the specific virtue of hope? Might the burnout phenomenon actually represent a shared sense of hopelessness for today’s residents, mired in a job that places undue stress to work toward a goal that seems difficult to discern? Hopelessness for patients who seems beyond healing? Hopelessness for a broken profession that seems beyond renewal?

High rates of practitioner dissatisfaction, mental unhealth, and overall disillusionment with the profession itself pervade the medical community, exacerbating what we see as a crisis of meaning and moral formation in medicine for which hope seems fleeting (B. Eberly 2020, 80). Even those who understand their work as morally meaningful may come to be literally “de-moralized” by the technological and bureaucratic pressures of modern medicine (Blythe and Curlin 2018, 431) (Curlin 2016, 62). For residents in particular, talk of “hope” among a generation quite familiar with burnout is often met with skepticism. Surprising as it may be, there is precedent for this. Plato, Euripides, Francis Bacon, and Benjamin Franklin are counted among those who have named hope as foolish (Bryan 2007, 212). COVID-19, the political landscape, and the challenge of racial discord in 2020 have no doubt only amplified this skepticism for contemporary trainees.

While commonly-held conceptions of hope may be popularly understood as merely a feeling or instrumentalized as yet another tool for wellness, we argue that hope is in fact a deeper character trait: a central and indispensable constitution for the practice of good medicine—necessary to sustain the resident in her work. In the other words, we argue that hope is a virtue—and one foundational to the practice of medicine. Perhaps, then, what is needed for the resident to flourish is not the current emphasis on wellness-based activities that seek to keep tired medical workers just hopeful enough to survive among an atmosphere of hopelessness but a clear understanding of the virtue of hope and how to pursue it—even and especially among those corners of medicine that seem particularly devoid of this powerful virtue.

If it is hope that is lacking for residents and thus hope that trainees need to grow toward, how are we to understand hope? Writing as both trainees and leaders involved in resident education, we will seek to provide a definition of the virtue of hope for the medical resident and to describe how hope as a virtue is integral to our work even as it is often difficult to develop. We will conclude by offering a brief constructive account of how such hope may be cultivated through community, lament, purpose, and action.

Virtue, Medicine, and Hope

Many have argued for the importance of virtue to sound medical practice. German internist Carl Wilhelm Hermann Nothnagel said over a century ago, “Only a good man can be a good physician” (Hoenig and Thom 2018, 453). The psychiatrist and historian Félix Martí-Ibáñez (1968) said something similar in his 1960s classic “To Be a Doctor”: “to be a doctor, in the truest sense of the word, is to be not only a wise man but, above all, a good man” (p. 4). William Bynum opens The History of Medicine: A Very Short Introduction noting that patients have always sought good physicians, but what has changed through time is what constitutes “the good doctor” (Bynum 2008, 4).

Clearly, medicine has traditionally been understood as not only a scientific endeavor but also a moral practice, requiring certain character traits on the part of the physician to be done well. Philosophers ranging from Aristotle and Thomas Aquinas to the more recent work of Alasdair MacIntyre and Edmund Pellegrino have recognized the necessity of the moral life and the practice of virtue for the work of medicine. Pellegrino has perhaps written most extensively about this, joining with David Thomasma in identifying the necessary virtues for physicians in their aptly titled 1991 text The Virtues in Medical Practice. They name compassion, fidelity to trust, practical wisdom, justice, fortitude, temperance, integrity, and self-effacement as the necessary virtues for the medical life (Pellegrino and Thomasma 1991). As Pellegrino (1987) put it elsewhere:

The patient, on his part, is forced to risk exposure of his body, life, and emotions if he is to be healed. He knows that, in the moment of clinical truth, his ultimate safeguard is the moral integrity and character of the physician. Yet he has no assurance of his physician’s character or commitment. (p. 75)

In spite of recognizing the importance of moral integrity, virtues, and character to medical practice, one virtue that has received comparatively little attention is that of hope. Such an absence is puzzling, as it would seem that hope is central to the experience of both patient and physician. The very act of the sick seeking out the care of the physician entails a hope in healing—or at least a reasonable expectation of some future relief. Likewise, physicians must maintain some level of hope in their ability to bring about healing—even if such healing is fragile, fleeting, or unlikely, such as in the Intensive Care Unit or near the end of life.

Absent the cultivation of genuine hope, it seems self-evident to us that the practice of medicine would prove difficult to sustain. The physician who displays hopelessness and offers no hope for patients instills a sense of despair (Pellegrino and Thomasma 1996, 60), undercutting the basic, primordial assumption that the act of seeking out the help of the physician may result in healing (Lynch 1974, 48). At the same time, the physician who hands out hope too easily risks building false confidence. Therefore, as medical ethicist Jack Coulehan (2005) puts it, hope is “a vital virtue for the practice of medicine” (p. 91). Before we explore how, we turn to define hope.

What Is Hope?

The word “hope” comes from the Anglo-Saxon hopa, meaning “expectation” (Bryan 2007, 212). While hope has corollaries across human traditions and communities, it is perhaps most developed by the Christian tradition where it is understood as a theological virtue distinct from moral and intellectual virtues. While intellectual virtues deal with the mind (wisdom, judgment, and knowledge) and moral virtues deal with the will (courage, honesty, and fortitude), theological virtues deal with one’s soul or essence (Kreeft 1992, 73; Marcum 2012, 83).

Importantly, theological virtues are not exclusive to a theological worldview; they deal fundamentally with issues of transcendence and ultimate meaning, especially in allowing one to seek the good of others rather than exclusively the good of oneself (Marcum 2012, 88). Obviously, secular persons can and do embody theological virtues insofar as they work toward the flourishing of the “common good,” though here we draw from the rich analysis of hope specific to the Christian tradition.

In the New Testament, hope is one of the three core theological virtues listed by the apostle Paul in addition to faith and charity. Paul understands hope as a “patient expectation of God’s ability to fulfill promises” (Marcum 2012, 88). In the third century, St. Augustine elaborated on Paul’s understanding of hope by noting that the virtue of hope involves “only what is good, only what is future, and only what affects the man who entertains the hope” (Augustine 1961, 8). A thousand years after Augustine, St. Thomas Aquinas further described hope as virtue that enables those to work toward attaining a good which is difficult to achieve—a disposition central to the ability to overcome adversity. As an Aristotelian, Aquinas understood hope as a balance between the dual vices of unwarranted pessimism (despair) and unwarranted optimism (presumption; Pellegrino and Thomasma 1996, 65; Geach 1977). Whereas despair views the good as unattainable, presumption views the good as too easily attainable, underestimating the moral effort necessary to realize it. Hope, in contrast, allows for a sound appraisal of the obstacles at hand while seeking realistic ways to overcome them. ¹

From this exploration of the Christian virtue of hope, we can see that the virtue of hope entails four core elements: a sound apprehension of the good, a clear appreciation of the barriers to that good, a forward-looking orientation in the face of uncertainty, and an ability to spur direct effort and action to bring the good about (Nunn 2005). With medicine in mind, then, consider that physicians must first and foremost have a sound practical reason, a firm ability to understand and apprehend the good in their patients and themselves (Kaldjian 2014). Second, physicians must also have a firm understanding of the obstacles to that good. These obstacles may reside in pathology, social determinants of health, or even within the profession of medicine itself. Third, the practice of medicine indelibly involves a forward-orientation despite a constant element of uncertainty, dealing as it does with the intractable nature of the disease, suffering, and the sometimes “gray” nature of medical decision-making. Fourth and finally, a physician must ultimately learn how to act in the face of such uncertainty, to be spurred on when he or she does not have all the answers, and to seek out practical actions toward the good of her patient’s health.

Foolish Hope

As we examine the elements of the virtue of hope (its apprehension and expectation of good, attention to the obstacles at hand, forward orientation, and direct effect on the person exercising the virtue), it is important to name clearly and candidly why residency poses a particular challenge to those seeking to cultivate this virtue. As we’ve already mentioned, talk of hope is often met with skepticism and for good reason.

First are challenges to the ascertainment and expectation of what is good—the good not merely in a subjective sense but in a normative one. While it may seem that medical training allows for moral development that makes for “good” physicians in the sense described by Nothnagel and Bynum above, we have reason to believe this is not the case. Sustained attention to the so-called “hidden curriculum” has named this moral deformation process over and over (Hafferty and Franks 1994, 861). Many in medical training may fail to develop the moral reasoning so central to the practice of good physicians (Murrell 2014, 219), even experiencing so-called “empathy decay,” “ethical degradation,” and “moral injury” (Betzler 2018, 569; Feudtner, Christakis, and Christakis 1994, 670). And while we may be tempted to view the moral challenges of medical training and the despair that may ensue as a novel phenomenon—unique to the last few decades of practice—the reality is that traces of this have been present long before the term “burnout” was even coined. Take, for example, this sobering reflection by Long (1960):

All have had the experience of walking down the hospital ward and witnessing a team composed of a resident, interns, nurses, and aids laboring with a patient who has cirrhosis, and who is in “hepatic” coma. We know that many hours and thousands of dollars may be expended in the care of this patient during the episode of coma, and that if the labors are “successful” the patient will emerge again into a painful, hopeless existence, which will eventually be climaxed by a fatal hemorrhage, or by coma and death. Next to the cirrhotic, there is a patient suffering the tortures of the damned because of the pain of tumor metastases, who has pneumonia. He is being vigorously and successfully treated with penicillin. His suffering will be prolonged.…In the next ward, a senile old crone gibbers at us, abandoned and totally rejected by her family, who already committed to a modern, overcrowded and understaffed modern Bedlam is waiting to recover completely from a staphylococcal bacteremia originating from a bed sore which had exposed her sacrum to the view of anyone who desired to look. (pp. 613–14)

The challenges of residency can prime trainees toward this kind of lurid hopelessness. Medical students may internalize the cynicism displayed by interns, interns may unconsciously imitate the world-weariness of their senior residents, and so forth. As has been written elsewhere, the medical training process is a powerful meaning-making framework of moral formation that teaches not only technical expertise but also what type of people trainees might aspire to become (Kinghorn et al. 2007, 40; J. B. Eberly and Frush 2019, 414). This moral deformation may not always take the form of overt misanthropy; the initial vision of medicine as an opportunity primarily to help the sick and serve the vulnerable may gradually be eroded by a constant emphasis in training on efficiency, quality improvement, financial throughput, or other concerns.

Second is the challenge to an accurate understanding of the obstacles toward achieving health for the patient. As mentioned above, these obstacles may be found in the dual vices of both presumption and despair. Presumption may lie behind the shock many trainees experience when faced with the true difficulty of residency or for those trainees who recurrently demonstrate that they “don’t know what they don’t know” amid the rigors of medical training. This presumption may also misunderstand or underestimate the significant fortitude required to care well for a dying patient or to withstand the disrespect of the so-called “difficult patient” or to remain engaged and committed while working with difficult superiors (Hawking, Curlin, and Yoon 2017, 357).

It is also easy to see how despair may sink in when residents recurrently experience challenges in the complex patients they care for, the frustrating structural and bureaucratic obstacles present in the systems they are a part of, and their own lack of experience and confidence in such moments. It is this despair that manifests in the high rates of depression, substance abuse, and suicide among medical trainees attempting to cope in such a system (Dyrbye et al. 2014, 443).

Third is the challenge to acting in the face of uncertainty for the resident. Medical students fresh off of the somewhat controlled environment of medical school often struggle with the intractable nature of real medicine and real patients. In practice, abstract algorithms and evidence-based guidelines frequently fail in the face of complex, enfleshed patients. Such uncertainty pervades the medical training experience and can paralyze nascent trainees—and it is precisely here that hope must spur the trainee on, that something good may come of decisions made in suboptimal circumstances. Yet it is also true that a certain dulling of this hope may set in as one progresses throughout training if one allows the outcome of an intervention to serve as the definitive word on one’s success as a doctor. In many cases, residents may work to move forward in the face of uncertainty, can make sound decisions, yet still experience unwanted outcomes. Hope cannot merely lie in the efficacy of intervention or the vicissitudes of what is often an inexact science.

Fourth and finally is the challenge that training poses to spur the resident forward. Hope, properly understood, has the characteristic of not only helping the resident to understand the good but also disposing the resident to act toward the good. This “moving forward” is different than mere “moving.” As physician and philosopher Jeffrey Bishop has argued, modern medicine tends toward a posture of “thoughtless doing,” meaning that medicine inculcates a view that obsessively focuses on “next steps” rather than working toward some higher “end” or purpose in medicine. High rates of attrition and physician suicide point to the fact that the challenge of trainees to be “spurred forward” within a purposeful goal is not merely a theoretical issue but an existential one.

When a resident lacks a view of the good, and perhaps feels that she is participating in a system that either does not strive toward this good or works actively against it, it requires a Herculean effort to move forward in the tasks asked of her. As Viktor Frankl famously noted while in Auschwitz, drawing on Nietzsche: “He who has a ‘why’ to live can bear almost any ‘how’” (Frankl 2006, 91). The inverse is also true: “he who has no ‘why’ to live can bear almost no ‘how.’” Without a “why” or purpose guiding the trainee, the “how”—the process of moving forward—will prove almost unbearable.

Practicing Hope in Residency

It is interesting that hope has distant etymologies no longer in use—in particular that of a “sloping ridge between mountains” as well as a “haven” (Wiktionary 2020). In light of the challenges to hope which residency presents, we think of hope as both a difficult slope and a worthwhile haven—a mountainous trek that leads to a resting place worth the pursuit. To this end, we hope to offer resident physicians footholds in the formation of the virtue of hope. As oncologist Jennifer Lycette put it in 2016, hope is not something promised so much as “practiced” (Lycette 2016, 431). Indeed, virtues require practice until they become habits or dispositions. Hope as a virtue is not a formula but a posture. As we consider the four qualities of the virtue of hope and the significant challenges that residency training poses to each of these, we turn in conclusion to community, lament, purpose, and practical action to cultivate hope in training.

A Community of Hope

Many of the philosophers we’ve already mentioned—Aristotle, Aquinas, Alasdair MacIntyre, and sociologists like Peter Berger—all note the importance of community to the cultivation of virtues. What is needed first for the development of hope in residency is a community to sustain those seeking to understand, develop, and practice the virtues.

Such a community helps to sustain the weary resident when she becomes fatigued and disillusioned and helps provide some forward orientation to worthwhile goals when the work of endless documentation and checklists threatens to overwhelm the resident. In this sense, such communities not only serve to educate and fortify but also serve to remind residents of the goods to which they are called (Hauerwas 1986, 80). At the same time, it may be especially important for residents to find moral communities outside of the hospital and to reorient them to a vision of the good that can help clarify the powerful moral system into which they are steadily inculcated in medical training.

A Posture of Prayerful Lament

How do we exercise the virtue of hope when hope seems impossible? As noted above, hope requires the exercise of practical reason—a sound moral and intellectual assessment of the situation at hand. Sometimes, this sound assessment accurately names a situation as especially dire—one where the obstacles are real and seemingly insurmountable, where the patient continues to get sicker despite intervention, where there truly seems to be very few redeeming elements of a given rotation. How, then, is the resident to practice hope when it seems that there is no hope to be found? When she makes a mistake, when she suffers from depression, when a patient passes away, when Mr. Jones returns again and again?

The first, crucial step is to recognize that the proper response to such obstacles is not always the hard-wired impulse to double down and trust in one’s own fortitude. Rather, the exercise of practical reason in such instances points toward the need for humility and one’s acknowledgment of one’s limitations—and the attendant necessity of prayer. It is only through the prayerful reflection of one’s own finitude in the face of daunting circumstances, and the clear need for God’s grace in place of one’s efforts, that hope can be sustained.

And yet even this prayerful acknowledgment still recognizes that hope—given its orientation toward something that has not yet happened—entails a sort of wiling risk of disappointment. This may be hope’s most counterintuitive characteristic. Hope holds open lament in the face of that which is hoped for never coming about. And yet, as anthropologist and philosopher Douglas Christie points out, it is precisely this willing descent into vulnerability, doubt, uncertainty, and even hopelessness that is the paradoxical path in which caregivers might become hopeful “bearers of compassion” (Christie 2013, 299). It is precisely the hope of the resident physician, well attuned to the real likelihood of death and suffering, that constitutes what J. R. R. Tolkien called “hope without guarantees” (Tolkien, Christopher, and Carpenter 2000, 237). It is important to name hope in this way, not as a rose-colored optimism but as an eyes-open expectation of something good and worth fighting for, even if (and especially when) it is not guaranteed.

When what we hope for fails, the resident might consider the prayerful response of lament. Lament is both a form of prayer and a spiritual practice found in Jewish and Christian Scripture in which one can openly and honestly name fears, disappointments, or injustices precisely where hope may seem to be fleeting or lost. Such lament is distinct from the vice of despair, precisely because it involves truth-telling of what has happened and expectation of future good. As physician Abraham Nussbaum puts it, hope in medicine is “a way of making peace with the past” (Nussbaum 2016, 248).

Identification of a Purpose

As we’ve written above, the forward orientation of hope and emphasis on “doing” in medicine more generally can spur anxiety in the resident and cause a sort of “paralysis by analysis” preventing the resident from acting with practical wisdom. Yet the difficulty of medicine can also have the effect of simply causing the resident to narrow her vision, to choose to view only what is directly in front of her in a sort of “blindness by near-sightedness.” The resident trudges on with the “how” without ever considering the “why.”

But if one is to truly cultivate and sustain the virtue of hope in medicine, it is critical that she identify the purpose of her work and perhaps the source of that hope. Ideally, this helps to sustain her in those moments of difficulty to remember what she is working toward. It is precisely that “why” that Nietzsche speaks of which can animate the “how.”

This process of identifying purpose entails intentional introspection on the part of the trainee. It involves asking very basic questions, but ones that are infrequently asked: “Why do I want to be a doctor?” “Why should I be a doctor?” “What is the ‘end’ or purpose of medicine?” “What is the nature of my relationship with the patients I serve?” “Is there some higher purpose, some telos, to which my work is oriented?” and “If I can’t reconcile what I experience in medicine with what I hope for, what then should I do?”

Such big-picture questions may seem to the resident to be extraneous to her job. Yet it is precisely these big-picture questions that must be considered to help clarify why it is that she sacrifices so much in the course of her work. Ideally, such questions should be asked prior to the training process but should also be revisited throughout training, especially during times of adversity (B. Eberly 2020; J. B. Eberly and Frush 2019, 414).

Hope in Action

Fourth and finally, it is crucial for the resident to identify role models who embody, practice, and teach the virtue of hope. The importance of a moral community outside of medicine is critical, but it is also essential that the resident identify mentors within the practice of medicine who serve as moral exemplars for this (Yoon et al. 2018, 149).

Such role models may be supervising residents, chief residents, attending physicians, or those in places of administrative leadership. Yet the prudent resident must recognize that she can learn from many people—not merely those in places of higher relative authority. Thus, the weathered but wise nurse, the encouraging member of the custodial staff, perhaps even a medical student on the team, can serve as examples of the hope the resident strives for, inspiring her to go and do likewise. The resident should be intentional about learning from these neighbors—perhaps making notes on her patient list just as she might do when jotting down a teaching pearl on rounds. This may also mean seeking out potential mentors known for their hope and asking how they have come to develop such a virtue amid a medical system that so frequently works against it. Through this process of seeking out role models and mentors, the resident may understand herself as a role model of hope to others (Gerber 1979, 659).

It is through this work of identifying such mentors and moral teachers, perhaps those who themselves have found moral communities outside of medicine, have adopted some practice akin to lament, have determined (and can articulate) the purpose of medicine and their place in it, and have found their own role models, that the resident might come to one day cultivate hope in others, practicing medicine as a hopeful resident.

Biographical Notes

Benjamin W. Frush, MD, MA, is a third-year resident training in internal medicine and pediatrics at Vanderbilt University Medical Center in Nashville, Tennessee. He is a former fellow at the Theology, Medicine, and Culture Fellowship at Duke Divinity School; a former Paul Ramsey Fellow at the Center for Bioethics and Culture Network; and a former fellow at the Fellowship at Auschwitz for the Study of Professional Ethics (FASPE). He is interested in how theology and moral philosophy can inform the ethics of medical training.

John Brewer Eberly, MD, MA, is a second-year resident in the AnMed Health Family Medicine Residency Program in Anderson, South Carolina. He is a past fellow of the Theology, Medicine, and Culture Fellowship at Duke Divinity School; a current Paul Ramsey Fellow with the Center for Bioethics and Culture Network; and a graduate of the University of South Carolina School of Medicine. He hopes to practice and teach at the intersections of medicine, aesthetics, ethics, and theology.