ten

COMMITTED

Hospitals often post quotations from Osler, but consultants write our slogans.

Halfway through residency, a new CEO took over the C suite at the academic medical center in Chapel Hill. Like the owner of a new home, he gave the place a makeover. He hired consultants to interview employees, organize focus groups, and compare the hospital’s outcomes with those of peer institutions. The consultants recommended that we increase high-margin procedures, eliminate low-margin services, and rebrand the hospital. Consultants wrote a new marketing slogan to describe the plan and organized meetings for each department at which they informed us of our future and announced the slogan that embodied it. At the end of each meeting, assistants offered attendees a T-shirt with the hospital’s new slogan on the front in block letters. Then the consultants flew home.

The T-shirts sat in boxes, uncollected. In the subsequent weeks, the hospital kept offering the free T-shirts to employees. At four in the morning, I would be five patients behind in the emergency department, my pager going off every few moments while ill people sobbed to themselves behind thick doors. A voice, like that of an unnamed minor divinity, would suddenly come from the loudspeaker in the ceiling. “All employees are invited to the second floor to collect their free T-shirt and show their pride in our hospital’s mission.” I never saw anyone leave a bedside or nursing station to get a shirt; the nurses and physicians were all firmly harnessed to the heavy carts of patient care.

The T-shirts were dumped in the hospital’s surplus clothes closets. A few weeks later, I started noticing them on rehab patients on the eighth floor, then on ward patients on the fourth floor. The shirts seemed to be making their way down the stairs of the hospital’s bed towers floor by floor. It was only a matter of time before they got to the psych unit on the third floor.

I saw them appear one Monday morning when I arrived at the psychotic ward, an eighteen-bed unit where most of the patients were being held involuntarily. We had several new admissions. Most of the new patients were wild-eyed and ranting. Some were hollow-eyed and shuffling. Some wore their own clothes. But others wore the new T-shirts, with the consultants’ slogan across their chests: “I’M COMMITTED!”

I think of those T-shirts and their unintentional insult when I sit through yet another presentation from a consultant about how to transform medicine by adopting disruptive and innovative techniques. They use peppy slogans, folksy anecdotes, and passive-aggressive dicta such as, “If you don’t like change, you’re going to like irrelevance even less.” (I often fantasize about asking them to speak that way to our patients.) The consultants are not fluent speakers of the language of medicine. Their native tongue is business, and they often describe the hospital as another industrial site that should respond to the kind of industrial practices that work in factories. They describe patients as consumers and physicians as providers of healthcare services. But describing us as providers misses the role that physicians—as well as nurses, pharmacists, social workers, and other medical practitioners—still have as craftsmen and women.

I never hear consultants or basement speakers describe medicine as a craft, but some of the old physicians still walking the floors of the hospital will pull me aside at staff meetings or at the nurse’s station late on a Saturday evening to talk about it that way. They appreciate the way science was used to inform medicine after Flexner’s Report, but confide that medicine used to be something more than a job, even something more than a profession. They “practiced” medicine because they were always improving their craft and passing it along to the next generation. Like carpenters or bricklayers, they traveled about as journeymen, seeking experience in their craft. They found a master, apprenticed themselves to the master, and became, with effort, masters themselves. These old physicians remember the first morning they scrubbed in on a thoracotomy, the evenings they spent practicing their sutures on a scrap piece of beef begged from the butcher, and the year they learned to replace joints alongside an august physician. They accreted experiences while slowly, repetitiously developing their craft. These old physicians tell the stories of when physicians were craftsmen and women who learned from master physicians instead of from standardized curricula or datasets or market trends. Wisdom was won, was earned—not derived. These old physicians disliked slogans, but they loved to share a maxim or two that they had learned from their masters, maxims that had guided their practice of medicine.

These maxims referred to the many prudential judgments a physician makes in a day, never to the biostatistical measures that evidence-based medicine advocates designed to guide clinical practice—no Number Needed to Treat or Number Needed to Harm, as measured in the Cochrane reviews—but practical reasoning for determining the best action when confronted by competing options.

Common things are common. When you hear hoofbeats, think horses not zebras.

Local pain is a danger. Widespread pain is a bother.

Think twice, cut once.

Heal with steel.

All bleeding eventually stops.

Good judgment comes from experience. Experience comes from poor judgment.

Many of these maxims relate to surgical practice, presumably because surgeons take the risks of going beneath the body’s surface. In our own way, psychiatrists are also interested in what lies beneath the surface. Yet we engage the intimate details in different ways. Psychiatrists probe by means of questions, silences, and suggestions. Surgeons probe with hands, scalpels, and scopes. Like us, they sometimes err when they probe, so they think a lot about mistakes and how to prevent them.

At the hospital where I trained, many of the surgeons wore cloisonné owl pins on the lapels of their white coats. The pins intrigued me because they looked like they belonged on the naphthalene-perfumed coats of elderly symphony-goers, not on the priestly coats of surgeons, and I could not figure out the pattern of their distribution. I saw the pins on attending surgeons and chief residents and, on occasion, on the coat of a surgical intern.

Finally, I asked a surgical resident, “What’s the deal with the owl pins? They make you look like my grandmother.”

“You get one for taking out a healthy appendix.”

“What? Why would you be rewarded for removing a healthy organ? Is this like handing out ribbons for surgical sadist of the week?”

“No. The idea is that appendicitis can be so deadly that it is better to remove a healthy appendix than to miss a ruptured appendix.”

“Oh. So why the owl?”

He sighed, exasperated at the incessant questions.

“The owl is a symbol of wisdom, of making the right decision, the wise choice—it’s better to save a life and lose an appendix than to save an appendix and lose a life.”

His old-lady pin was really a merit badge.

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The idea of rewarding wisdom, encouraging a physician to develop prudential judgment, is in disrepute. Cochrane and the pioneers of evidence-based medicine disliked the ways it relied upon anecdotal evidence: miss one ruptured appendix and you are likely to take out a hundred healthy appendixes. Today’s quality-improvement advocates dislike the way that prudential judgment leads patients through unstandardized scripts to inconsistent outcomes. In the same hospital, different surgeons have very different rates of appendectomies. Multiplied over a population, startling differences in surgical rates occur.

Both concerns have obvious merit. Both concerns also neglect the ongoing need of physicians to make wise judgments.

Physicians need to exercise judgment in applying evidence-based literature to a specific patient. Even if you have mastered the best evidence, you still have to know how to curate, integrate, and apply the evidence to the patient before you, especially since there is often limited evidence available that applies to a specific patient.

On the psych unit, we suffer this problem every day. The acute treatment of persons with schizophrenia usually includes a medication to reduce the symptoms of psychosis. There are many randomized clinical comparison trials of the various antipsychotics. These trials, however, typically exclude persons who also abuse substances or who have unstable living situations. The former confuses the effect of the treatment, and the latter makes it hard for participants to finish a study protocol. But the result is that we have to extrapolate from the populations in clinical trials to the patients in front of us, who are often more ill and more impoverished than the more stable subjects who populate the evidence-based literature.

A few months ago, Doreen was the patient in front of us, fresh off the bus from New Mexico. We admit ill travelers like Doreen daily because most counties in the state, even in the surrounding states, have no psychiatrist. People who need to see a shrink have to come to Denver. The city sits at the foot of the Rocky Mountains and at the intersection of two interstate highways. I-25 runs vertically along the Rockies most of the way from Canada to Mexico. I-70 travels horizontally, spanning much of the distance from the Pacific to the Atlantic. When a passenger becomes manic or psychotic on a bus, the driver is encouraged to keep the passenger on board until the bus, whether it has to traverse mountain passes or the eastern plains, can stop in Denver.

Doreen ran onto the bus in Las Cruces, still tweaking on meth, collapsed into sleep before Albuquerque, and woke up raving when the bus entered Trinidad. The driver radioed for help. Dispatch told him to clear her aisle, belt her to her seat, and head north to Denver. Officers would be standing by.

By the time Doreen reached our floor, she was still paranoid, but the intramuscular haloperidol and lorazepam given to her in the Emergency Department had filed down the ragged edges of her agitation. She told us she had fled New Mexico to escape “vampire dealers selling me poisoned shards.” She disclosed a history of schizophrenia and meth use but could not explain which came first. The medical literature provided guidance on each problem, but when it came to someone with both problems, the literature offered none of the high-level evidence we are supposed to rely upon. We were left with our own judgment. She had been calmed by an initial dose of haloperidol, so we prescribed it to treat her symptoms. She became less paranoid, but was that because of the haloperidol or because the meth was dissipating from her body? We could not say, but either way, we knew what the next step should be.

Whether her meth use came before or after she developed a psychotic disorder, it was surely one of the obstacles to health that Hildegard would have pruned away. So we asked Doreen if she was ready to quit meth. Since our unit is a teaching service, modeled after Osler’s own, I let the resident make the first attempt at helping Doreen quit. He ran through a list of problems meth can cause. Anxiety. Confusion. Insomnia. Kidney damage. Lung disease. Memory deficits. Mood swings. Strokes. Tooth decay. Then he paused.

“Can you see, Doreen, why you should stop using meth? It will affect every part of your body, even your teeth.”

“No, I’ve never had any problem with my teeth. None of my friends have problems with their teeth. They all use meth. One of my friends, she gets up in the morning, uses a little meth, gets groceries, does her prostitution thing, comes home, and makes dinner. She does fine. I do fine. Fine. Meth just helps you git. Sure, sometimes you get loopy. I mean, sometimes, I have to hide behind the dresser to keep calm. I stay there a few days. It’s okay. I get hungry? My husband will chuck a burrito over the dresser. No problemo. I’m ready to head on out, get back on the bus and head for Sweetgrass, Montana.”

“What’s in Sweetgrass?”

“End of the highway. Sweet grass. Get it? End of the road. Where all the grass is sweet. Suweeeet.” She laughed and bared her teeth. Some discoloration, poorly aligned, but intact.

She had been on the unit for a couple of days and had not acted out. She took the meds we offered her, reported feeling fit, and asked to leave. She was not ready to quit meth, but she was an adult. She forced the question: Was she ready to be discharged? Doreen was a sixty-two-year-old woman with little money, a psychotic disorder, a meth habit, and a history of disruption on the bus. For her to get back on the bus, and ride to the road’s end in Sweetgrass, she would need a bus ticket from the hospital and a physician’s note saying she was safe to ride. A note I would have to write.

I wanted Doreen, and everyone on the bus she boarded, to be safe, but there was no class in medical school or residency that taught us how to determine whether or when someone was safe to ride a bus. The question was critical, but there is no evidence-based answer to it, no computerized algorithm to follow.

Instead I thought of a maxim, oddly appropriate to this exact situation, that one of my senior physicians had shared with his medical students. When students asked him how they would know if a patient was ready to leave the psychiatric hospital, he told them, “If they would spook the riders on a bus, keep them overnight.” We kept Doreen.

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If you read medical journals and op-ed pages, you might think that prudential judgment has been banished from medical practice. Today’s maxims are business maxims, such as “automation with a human touch.” The traditional model of the physician as an artisan who learns how to make wise choices from master physicians is out of fashion with healthcare’s technological and policy elite. The irony is that it has fallen out of fashion at the exact moment that the concept of craft is otherwise embraced. Brewers, butchers, and cheesemakers celebrate craftsmanship. They emphasize that their beer or beef or cheese was prepared according to recipes perfected over generations.

Such claims can be an affectation. Over the past decade, the meaning of foodies’ favored adjectives—artisan-made, handcrafted, local, organic, and small-batch—has been exhausted by overuse. Reclaiming them for medicine seems passé. And absurd. I enjoy Trappist beer brewed the way a monastery has been brewing it for centuries, but I do not want to prescribe the medicines Hildegard of Bingen compounded in her abbey. If I fall ill, I do not want fennel seeds from a garden, but studied and standardized doses of medication and safe anesthesia. And yet, I would still want a physician who could see a patient as well as Hildegard did.

In medical school, I discovered a small book that taught me what it means to see a patient well. In Les yeux de la foi (The eyes of faith), the philosopher Pierre Rousselot discussed a technical philosophical question about how Aquinas understood intelligence.1 To make the question less technical, Rousselot offered an analogy. Two detectives are dispatched to a crime scene. Upon arrival, they inspect the scene together and notice the same detail. The first detective sees the detail as a clue and solves the crime. The second detective notes the detail but makes nothing of it. While the two detectives had observed the same detail, only the former was able to make use of it.

Why could the first detective solve the crime while the second detective could not? Was the first detective simply more knowledgeable or experienced?

Rousselot insisted otherwise. He said the difference between the two detectives was that the first detective used his knowledge as a way of seeing. He saw the crime scene with his knowledge of the law, and a detail was known as a clue, allowing him to solve the crime. Rousselot wrote that the crucial difference was whether knowledge was employed as a vision: the vision of the first detective joined the proof (the clue) and what was proved (the law).

I thought of the physicians I knew and the ways they were like Rousselot’s detectives. When the wise physician and unwise physician surveyed the same patient, the wise physician left the bedside with a diagnosis, whereas the unwise physician left the bedside as confused as when he or she arrived. Just as the first detective saw with the eyes of the law, the wise physician saw with the eyes of medicine.

Rousselot believed that we gained this vision by developing virtuous habits. When we engaged in the practices of the wise detective, he wrote, these practices became habits, and we eventually became wise detectives. In this formulation, a person could not learn such habits in a classroom or textbook, but only through practical knowledge. Rousselot’s argument implied that medicine is called a “practice” for a reason. We learn the virtues and habits of a good physician by repeatedly performing the practices of a good physician. For the good physician, diagnosis occurs as a flash of simultaneous perception and judgment. Wise physicians can quickly resolve ambiguous problems into precise diagnoses and prescriptions.

Rousselot’s account is a version of an ancient argument popularized by Aristotle. For Aristotle, we gradually achieve excellence by behaving excellently. We become just by behaving justly. We become courageous by behaving courageously. We become good physicians by performing the tasks that good physicians perform. It sounds circular. In the Nicomachean Ethics, Aristotle wrote both that “virtue is the result of habit” and that the virtuous “are completed by habit.”2

Aristotle’s argument has so much appeal that it has been engaged repeatedly in the centuries since he lived. Instead of focusing on the consequences of a particular action, Aristotle called attention to the qualities of the person who undertakes a particular action. He called those qualities arete, “virtue.” “Virtue” sounds as old-fashioned as vaudeville, virginity, and the village green. So some ethicists decline to translate it, preferring the Greek arete to the English virtue. They have a point, because arete has resonances beyond virtue. Translators of the Nicomachean Ethics define it as “the excellence of a specific type of thing, animate or inanimate, that marks the peak of that thing and permits it to perform its characteristic work or task well.”3 So to have arete is really more to be arete, to have developed excellent habits so thoroughly that you consistently perform them over time: these habits become who you are, your character. From a virtue ethics perspective, becoming an excellent physician is less about passing examinations that assess a minimum level of competency than about pursuing the ideal of being a good physician. The work is accretive and incremental. Virtue ethics emphasizes the everyday conduct that leads to a good character. In virtue ethics, you have to be virtuous before you can achieve an evidence-based outcome or follow a checklist.

That is why virtue ethics focuses more on developing practitioners than on developing rules. A virtuous person will have developed habits that will allow him or her to achieve excellence in multiple settings. The person who learns the virtuous habits of a good physician while training in Addis Ababa should also be able to practice medicine in Amarillo, even though the technical skills required in the two settings may be distinct. Instead of developing standard work or benchmarks, virtue ethics develops people. In virtue ethics, you recognize the distinctive nature of each person by accounting for his or her particular constellation of habits. You acknowledge the relationship between habits and feelings. Finally, virtue ethics explains why a person is a physician rather than simply employed as a physician. Being a physician, including the social aspect of the role, both depends upon and shapes a physician’s character.

The loss of our ability to account for these aspects of a physician and his or her work is part of what the older physicians are mourning when they lament what is happening to the field of medicine. Many mourn the loss of an era when physicians had more wealth and cultural privilege. (My grandmother, who lives in Amarillo, once, unbidden, took me on a drive through our hometown to show me the expensive homes of her physicians. General internists had above ground pools, cardiologists had in-ground pools, and vascular surgeons had pool houses.) But some mourn the era when being a physician was more than a job, when it was a calling or vocation that marked a person’s very character. Medical practice, they say, focused on pursuing excellence in service of an ill person, not pursuing outcomes. Outcomes and rules change all the time. New executives come to the hospital, and they prefer a different business theory. They distribute new T-shirts with new slogans. Or new regulators decide that different rules or outcomes will measure success. So when I graduated from residency, the advice a favorite teacher gave me—“Know your metrics. Rent for the first year.”—was good advice for the times, advice which reflected the shifting commitments of the hospital.

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The demands of the hospital, like a solvent, reveal a physician’s problems even in the early days of training.

When a student at the University of Colorado fails multiple clerkships, violates the honor code, or otherwise earns a certain level of unwelcome attention from the medical school, we assemble a “success team.” The team usually consists of a couple of representatives from the dean’s office, physicians who specialize in academic remediation, and me. My formal reason for being there is to determine whether a student’s failure has a psychiatric component.

We speak with the medical student about our concerns and considerations, but what we are really telling the student is that we doubt his or her ability to eventually practice medicine. Our implicit job is often to introduce the idea that the student will never have a career in medicine unless he or she is able to make changes he or she has, so far, been unable to make. This comes as a blow to most students, who, like their classmates, applied to medical school by writing essays about how much they liked science and helping people, and began training, usually on borrowed money, with the promise of a profession.

Any student who is smart enough to pass the exams, and stubborn enough to endure them, can get through the first two years and advance up Osler’s ladder. But while hospitals like smart physicians, what they need even more are industrious and responsible physicians. So as clinical training begins, the assessments change. There are still examinations, but they make up an ever-smaller portion of students’ grades. Most of a student’s assessment is based on his or her ability to behave like a physician. Does the student exhibit fortitude and self-discipline, the characteristics of a physician? The assessments concern whether the student can be trusted by peers and patients.

Some students feel disoriented by the shift in assessments. A few years ago, I worked with a student who lied about patient information and claimed that he had missed rounds to care for a dying relative. His excuses were suspect and when investigated found to be threadbare fabrications. When confronted in the dean’s office, he was defensive. He named his above-average exam scores and lack of interest in a particular rotation as reasons we should ignore his errors. As I listened to the student, I remembered Dr. Rogers’s admonition at the white coat ceremony: “Never forget that the worst stains spill from your own character: from neglect, impatience, or greed.” In attending to his intellect, the student had neglected his character.

When I think of my own errors in the hospital, Dr. Rogers’s warning also pertains: my errors more often issue from my stained character than from my lack of technical skill. On my bad days, I make judgments that serve my interests rather than the interests of my patients. I answer pages slowly. When I do return calls, I offer yet another medication over the phone instead of sitting with a distressed patient.

What is difficult for medical trainees to realize is that these kinds of failings become less tolerated the farther they advance. In his classic Forgive and Remember: Managing Medical Failure, the sociologist Charles L. Bosk described his eighteen months following a surgical service at a teaching hospital, where he found that different kinds of errors were treated differently. He wrote that supervising physicians “tend to be tolerant and forgiving of technical error and intolerant and unforgiving of moral error. This pattern of response shows us how moral competence acts as the organizing principle.”4 Surgeons, Bosk wrote, forgave technical errors as a way to signal membership within the community of surgeons. This explains why Chapel Hill’s surgeons handed out owl pins for removing healthy appendixes, while stringently punishing moral errors. These were the errors that could not be countenanced, the kinds of errors that could get a student dismissed from a training program. Or assigned to a success team.

What Bosk discovered as a sociologist is what physicians in training come to realize gradually. During the preclinical years, students believe they are studying science. Then they realize that they are not testing hypotheses but learning to apply scientific knowledge. During the clinical years, students believe they are receiving a technical education—how to start a central line, how to alter vent settings, how to titrate a medicine. Then they recognize that they are actually being given a moral education: although many can learn technical skills, what makes a physician is the desire to use these skills well for another person, to be sure the central line is in the right place, the vent settings are correct, and the right medications are administered even when one is exhausted and irritable, and to take responsibility for any errors that occur. Students find this realization confusing because it is not why they were selected. When they applied to medical school, they knew good-hearted peers who were rejected out of hand. Medical school admission is offered not to the virtuous but to applicants with the right scores from the right schools. Then in their clinical training, they are evaluated on their character. By the time they apply to residency, they are being graded on a moral curve. Grades and intelligence still matter, but good people who are less smart are often selected for coveted spots.

There is a sense to this. In a study of medical students, trainees, and attending physicians who required remedial work at the University of Colorado, Jeanette Guerrasio and her colleagues found that professionalism deficits occurred more frequently as a physician advanced in his or her training. They also found that professionalism deficits were the best predictors that a student would end up on probation during clinical work, a finding confirmed by many other studies.5

So when I am involved in a medical student’s success team, I listen for signs of mental illness, but what I worry about are character traits. In psychiatry, the so-called five-factor model enumerates five traits—agreeableness, conscientiousness, extraversion, neuroticism, and openness—that can be used to describe a person’s character. These traits are stable over time, and the presence of a single trait—conscientiousness—is as consistent a predictor of academic success as intelligence is.6 What I am listening for is often less about mental illness and more about whether or not a student is conscientious.

We do the same when a residency faculty meets to discuss which medical students to select for the next class of residents. The faculty values intelligence, but we require virtues like conscientiousness. So as we meet applicants, we grade them on whether they are self-disciplined and organized, whether they are developing the habits of a conscientious physician. During the resident selection process, just as during the medical school success team meetings, it becomes clear that physicians still perceive medicine as a calling, and that we still want and select for virtuous physicians.7

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Since we learn virtue by aspiring toward ideals, our education is a necessarily social process. We need someone to emulate, someone we aspire to become. Virtue requires at least that relationship, so virtue necessarily has a social shape, formed in relationships that foster habits and character. In the Middle Ages, guilds developed as one kind of relationship for inculcating virtues. The members of guilds controlled who could and who could not belong to their confraternity, who could practice its discipline, and who controlled its supplies.

Medicine is lousy with guilds. Every specialty has its own guild, often on regional and national levels (I belong, for instance, to the American Psychiatric Association, not the Canadian Psychiatric Association). These guilds also increasingly focus on a particular part or technique. Instead of joining the American College of Surgeons, a surgeon might join the American Society for Surgery of the Hand or the Society of Laparoendoscopic Surgeons.

Despite their proliferation, the influence of these physician guilds has decreased significantly since their mid-twentieth-century apex, when the largest physicians guild, the American Medical Association, established the rules for medical practice. In 1948, when national health insurance was nearing a reality in the United States, the AMA successfully defeated the legislation through what was, at the time, the most expensive lobbying campaign in American history. Today, despite the fact that a quarter of American physicians belong to the AMA, it lacks the influence to alter legislation of that magnitude. There are many reasons for the declining influence of guilds like the AMA, but one reason is that they act less like guilds nurturing the practical wisdom of physicians and more like trade associations defending the livelihood of physicians.

This can happen even when guilds embrace prudential judgment. In 2012, the ABIM Foundation, a nonprofit organization founded by the American Board of Internal Medicine to advance professionalism in medicine, announced an initiative called Choosing Wisely. The Choosing Wisely campaign was intended to strengthen the physician-patient relationship by discouraging the overutilization of medical services. The ABIM has the support of every major medical specialty board for this initiative, in which each of the major guilds identifies five or more ways to reduce the use of expensive and unnecessary medical interventions. But the lists do not read like the maxims of yore passed on by retiring physicians. The list written by dermatologists includes, “Don’t prescribe oral antifungal therapy for suspected nail fungus without confirmation of fungal infection”; the list written by internists advises, “In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test”; and the list written by nephrologists cautions, “Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.”8 The name of the Choosing Wisely campaign invokes the prudential judgment of medical maxims, but its maxims will never be turned into inspirational posters or appear on a T-shirt.

These lists are evidence-based medicine summaries, compact versions of a Cochrane review, and rough drafts for the algorithms that will appear at our workstations when medicine becomes as automated as the Cheesecake Factory’s kitchens. This is by design. The ABIM requires that the maxims be evidence-based. No owl pins allowed. No wisdom either, despite the initiative’s title. The goal of the initiative is not, in fact, to develop the prudential judgment of physicians. It is, like that of the kitchen managers in the Cheesecake Factory, to reduce waste in the medical system.

The initiative invokes wisdom while offering algorithms. Wisdom is a quality that was once so central to society that the Greeks and Romans personified it as a divinity. Now we use it as a decoration for our formulas about the efficient and effective control of a population.

Even worse, we physicians use guilds and language about wisdom to defend our livelihoods. So when Nancy Morden and her colleagues analyzed the Choosing Wisely lists, they found that guilds rarely suggested limiting the use of their most remunerative procedures, and they often named the procedures performed by other guilds as the ones that were wasteful and unnecessary and should be discouraged.9 We invoke wisdom, but do not practice it. We are ironic, ersatz Kraftwerkers playing at wisdom in industrial settings.

And yet virtue haunts medicine. You hear it in the medical maxims favored by the retiring physicians. You even hear it when physicians try to leave talk of virtue behind. When a group of physicians recently reviewed the various definitions of what it means for a physician to behave professionally, they found that “all expositions of professionalism, whether from professional organizations, accrediting bodies, or individual points of view, essentially devolve into descriptions of a virtuous person as physician, as well as the ways in which a virtuous physician acts.”10 We still want virtuous physicians, but we do not actively develop them, and our guilds no longer emphasize medicine as a craft learned over time in a community of wise physicians. But we still need to call on this kind of wisdom, as I realized when trying to figure out when to discharge Doreen. Thinking about the senior physician’s maxim, we kept Doreen for a few more days, longer than the national standards advised or her insurer paid for, and her thinking cleared. She safely rode the bus home to a New Mexico treatment facility, wearing a T-shirt we gave her, a T-shirt without a consultant’s slogan.