Holistic Lessons from a Pandemic: The Value and Necessity of Authentic Reflection

Usman Raja – University of Birmingham, Year 4 Medicine

Student Essay Competition 2020 – Holistic Lessons from a Pandemic.

We thought this was an excellent essay though it didn’t quite align with the topic set and therefore, sadly, did not qualify for shortlisting.

  • Commendation

“Medicine has become the art of managing extreme complexity – and a test of whether such complexity can, in fact, be humanly mastered.”

Gawande A. The Checklist Manifesto

Medicine, particularly in its recent history2, has long been victim to an identity crisis3. This crisis has borne debate around the ontology and categorisation of the medical field4-6 as well as the foundations upon which it should depend to guide its goals and principles7-10. While it is of value to deliberate over the nature of medicine, it ought to be acknowledged that the pluralism that has ensued has left the physician at a loss11. This ‘loss’ refers to the fractured identity that physicians experience and exhibit, permeating through to their very practice7,12.

‘Reflection’ has been one aspect of a doctor’s practice that has suffered due to the fragmentation. As medicine fights for its identity, the field has concurrently become reductive and instrumentalist, promoting a capitalist sense of production with respect to ‘health’ and the physician’s contribution13. The predominating notion of instrumentalism and production perhaps reflects the consistency of this theme among the multiple “bases” 3 competing for the soul of medicine or even the magnitude of medicine’s present dependence upon a reductive scientific doctrine. As a result, medicine has begot a concept of reflection that is lacking in its scope and may be more aptly labelled ‘pseudo-reflection’14.

Reflective practice has become a tool of assessment15, no longer an end in itself (where value is placed in the action) but rather a means to an end. Medical education must also hold responsibility for this reality, in that it promotes reflection within a framework of education that values memorisation, efficiency and target-hitting above all else16,17, perpetuating a manner of medicine where “carelessness and superficiality”18 thrives. Just as “healing”19 is lost from the semantic field commonly attributed to medicine and its goals for patients, so too does the term fail to draw necessary attention when discussing reflection. This is further exacerbated by the formalisation of the reflective process in the modern healthcare system, as fear of repercussions and a perceived lack of confidentiality prevent authenticity and impact the physician’s willingness to engage completely and truthfully with reflection20.

Authentic Reflection

What then is ‘authentic reflection’? In truth, it is an ideal that is difficult to encapsulate in words and is arguably an amalgamation of concepts such as Kant’s “reflektierende Urteilskraft”21 or Aristotle’s “phronesis“22. Kant, in describing reflection, states “it is a peculiar talent which can be practised only, and cannot be taught”21 and this presents a suitable foundation for building a framework within which to understand reflection.

Reflection may be considered an extension of the human response to emotion, be it emotion forged in moral distress or some other potent situation. Recent literature suggests that the medical professional’s moral distress may be overcome through the utilisation of phronesis, denoting an active and practical wisdom23. In this light, authentic reflection can be considered the necessary predicator to such a consistent approach or even the integral first step of this process, holding within its action the virtues of ‘moral courage’ and ‘wisdom’23.

Further, reflection may be thought of as an existential endeavour. Writers of a stoic persuasion proselytize a notion of reflection that may be interpreted as seeing defiance, grit and a ‘stiff upper lip’ as the means to navigate the emotive and challenging. While this manner has its benefits, the reflection that must be advocated for is distinct from the views advocated for by Seneca and Marcus Aurelius, among others. It is more suitably described as an active engagement of the self, akin to the Algazelian “muhasabah”24,25.

In the process of authentic reflection, the agent both recognises the turmoil brought forth and accepts the associated struggle to reconcile one’s beliefs and understanding of themselves and their surroundings, leading to a place of reconciliation, solace and ‘truth’. In this way, reflection becomes a liberating, transformative and enlightening experience. An experience which allows the agent to feel ‘whole’ and, in turn, simultaneously breeds grounded resilience, perseverance and passion.

While the above notion may well seem similar to the ‘journaling’ proposed by the stoic26, this process should be considered a distinct action in that it promotes a self-reflection grounded in the subjective experience, formulating “emotional movement”23, as opposed to a more objective approach, perhaps more aptly described as ‘rumination’. It is the latter understanding of reflection that has governed the reflection of the medical practitioner, in modern healthcare, prior to COVID- 19. Admittedly, there is value in a narrative approach23, however it is limited by the reductive framework of assessment, dominance of ‘reason’27 and the extrinsic motivation with which it is perceived by the physician.

For the reflective process to be truly realised, it must be intrinsically motivated and navigated by the physician. Moreover, this shift in motivation may, through the growth it provides, even allow the physician to have a more sustainable commitment and become more highly achieving within their field28,29.

The COVID-19 Pandemic and its Fruits

Medicine and healthcare are bound to the political, cultural and economic environment around them. The interplay of these factors (and indeed many others) is complex and discussed in-depth in medical literature30-33. The COVID-19 pandemic has affected all aspects of society and the norms the individual is accustomed to, prompting existential and ethical crises as societal axioms and customs are withdrawn and challenged34-36.

In addition to this, the physician has also become inundated with troubling experiences within their profession. The ideals to which they attempt to treat patients seem distant as many ethical dilemmas and challenges arise in the current climate37, such as healthcare rationing38and the disproportionate impact of COVID-19 on BAME individuals39,40. All of these factors amount to a cumulative and additional existential stress for the physician, particularly when considering their identity and duty. This stress is directly comparable to the ‘meaningless suffering’ that ensues as healthcare workers are prevented from carrying out their ethical ideals23, which Wang and Ko label “difficult ethics”41.

The overwhelming nature of the pandemic and the inability to escape from its grasp, as quarantines and lockdowns are imposed and infection-related terms become normalised in societal lexicon, may have provided fertile ground for authentic reflection to grow. Unable to ignore the pandemic and engulfed completely by it, the physician has become Geoffrey Vickers’ “agent-experient”, which Yancey refers to in her citation of Schon42. In the face of increasing demand and stresses, the principles of ‘slow medicine’43 have somewhat paradoxically taken hold, predisposing the physician to reflect authentically and conscientiously. This has led to an engagement with emotions and conflicts, as the physician has little choice but to ‘move’ through their feelings rather than dismiss or steer past them.

The aforementioned engagement, here synonymous with reflection, has led to the development of characteristics formed under immense stress and stimuli. These characteristics are perhaps ineffable but fall amongst the concepts of ‘resilience’44, ‘toughness’45 and ‘grit’20. Each term’s definition suggests that the reflective physician would become adaptable, dynamic and a participant in “intellectual humility”46. These prove to be necessary qualities for the doctor to succeed existentially and holistically (as a flourishing, ‘eudaimon’47 individual) but also in reference to the expectations laid before them by regulatory bodies48.

Indeed, this is further perpetuated by the prominent and recent recognition of the sacrifices and efforts of healthcare workers, by the general public49, in turn providing ‘permission’ to feel to the physician. A permission which previously has been denied by the culture and system of healthcare and its unwritten rulings, where healthcare workers must not use time to reflect but rather “pinball from one moment of crisis to the next”50. As the fallacy of the ‘invincible doctor’ is dismantled in the public eye and the physician’s struggle is understood and acknowledged, it follows that the physician may begin to self-actualise in an environment of awareness.

Conclusion

Self-care and self-actualisation have both been considered an ethical obligation in many philosophies and societies. This pandemic has the potential to transform modern society, into one that may more readily strive to this goal once more. For the physician, reflection is a predicate to achieving such an outcome and the healthcare system must begin to accommodate the existential aspects of reflective practice. Cannon states that “lives can be saved by listening to someone who has spent their entire life never being heard”50. If the pandemic does indeed allow for the physician to finally listen to themselves and for the development of a system that listens to such reflections, it follows that many lives, including the physician’s own, may well be saved as a result.

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