A Model for Humble Commitment in Medicine

Vishesh Jain //

Ostensibly, Wintersmith is a novel about witches. It follows young Tiffany Aching as she works as an apprentice and learns how to manage the vast and unexpected responsibilities of witchcraft. The reader, like Tiffany, may expect magic spells and supernatural phenomena to fill her life, but these constitute a fraction of her work. Instead, reading about Tiffany serving her community was almost like looking into a mirror of my own training in medical school:

Giving an old lady a bath, as much as was possible with a couple of tin basins and some washcloths. And that was witchcraft. Then they looked in on a woman who’d just had a baby, and that was witchcraft, and a man with a very nasty leg injury that Nanny Ogg said was doing very well, and that was witchcraft too. (Pratchett 283)

Apart from practicing medicine, witches hold unusual respect that renders them unofficial managers of their communities and adjudicators in disputes, from the ownership of land to the allocation of newborn puppies. When supernatural malignant entities do come calling, naturally it falls to witches to handle the dangerous situation. Pratchett’s portrait of witchcraft mirrors medicine’s characteristics and amplifies them – the chance of miracles amidst daily mundanities, the mantle of authority within a life of service, the burden of responsibility during high-stakes dilemmas. In this way, his novel provides a magnifying lens through which we may examine medicine and our role within it.

Unfortunately, the right course of action, as a witch or a doctor, is seldom obvious. Just as Tiffany is “not as certain of anything at all as she was a year ago,” I find myself with each new year more aware of how much I do not know, despite striving for knowledgeable wisdom (Pratchett 28). The personal challenge of insecurity is amplified by medicine’s fundamental uncertainty.  Few diagnostic tests can boast near-perfect sensitivity and specificity, and most treatments have success rates far lower than 100%. Whether predictable or not, it is difficult to face the negative consequences of our actions. In the first half of Pratchett’s book, Tiffany unintentionally catches the attention of the Wintersmith, leading this embodiment of winter to unleash his terrible strength in pursuit of her (Pratchett 317). After the subsequent death of her teacher, Tiffany struggles to take care of her village while also facing sheep-burying blizzards and ship-sinking icebergs (15, 243). From these supernatural events to more mundane errors, Tiffany initially bemoans the unexpected results of her actions, crying that “I didn’t mean all this to happen!” (88). Yet just as we physicians are expected to heal with certitude, witches must act as steadfast anchors within their villages. As Tiffany learns, “it was important to look calm and confident, it was important to keep your mind clear, it was important not to show how pants-wettingly scared you were” (17). The loss of such an anchor can cause a community’s web to fray, endangering lives and livelihoods. Insofar as physicians act as leaders within their healthcare teams, we carry a similar obligation for poised competence.

Despite this pairing of uncertainty and need for perfection, firm choices are crucial for clinical practice. Ultimately, I must decide on a plan, even in the face of my own imperfect knowledge or prior failures. If the etiology of a disease is unknown, perhaps diagnosis requires further testing, or perhaps a trial of treatment is warranted. If an attempted treatment fails or carries intolerable side effects, it is not acceptable to throw up my hands in defeat or to wail that it should have worked. Tiffany eventually accepts the responsibility inherent in her profession: “you could say it was unfair, and that was true, but the universe didn’t care because it didn’t know what ‘fair’ meant. That was the big problem about being a witch. It was up to you. It was always up to you” (Pratchett 350). Likewise, while patients are decision-makers in their own right and are evermore involved in their own care, the burden of responsibility rests on our shoulders. It is up to us to guide patients in choosing future paths, whether they be alternative therapies or changes to goals of care. If errors or adverse events occur, it is up to us to make amends.

Given that commitment is crucial, I find myself struggling with how to reconcile it with our imperfect knowledge and the world’s fundamental uncertainty. Perhaps by underpinning choices with humility, we can better navigate the unknown and the unknowable. First, humility about the extent of our knowledge prevents us from committing to beliefs with unjustified certainty. For example, if a therapy is attempted when the diagnosis is not certain (and often even if it is), humility allows a shared understanding between patient and physician that it may be unsuccessful. Second, recognition that our knowledge is a work in progress allows us to move from “I don’t know” to “I don’t know yet.” Not only does this promote a productive approach to difficult clinical scenarios, but it also serves as the foundation for a growth mindset. Searching for a model to routinely remind me of this practice, I found one in Wintersmith in the form of a mantra Tiffany develops for herself:

This I choose to do. If there is a price, this I choose to pay. If it is my death, then I choose to die. Where this takes me, there I choose to go. I choose. This I choose to do. (Pratchett 18)

As the lone witch watching over her people, Tiffany makes life-and-death choices for herself and others, because she must. She learns from those decisions, because she must. Her mantra provides a guide for humble commitment within our own work and lives. First, Tiffany accepts the potential costs of her actions, however severe: “If there is a price, this I choose to pay. If it is my death, then I choose to die” (Pratchett 18). These lines also begin to lay out her uncertainty; she is not sure what price may be leveled. Nevertheless, the humility therein does not absolve her of responsibility or free her from those consequences. We must similarly accept the effects of our actions, intended and unintended. Recalling the supernatural scope of witchcraft reminds me that my choices may affect patients in realms beyond their health, and that those realms must conversely inform my decisions. Looking forward from a given choice further into the future, Tiffany next highlights her intent not only to choose a path but also to follow it: “Where this takes me, there I choose to go” (18).  While also indicating her humble uncertainty about her choice’s results, this statement reminds us that most decisions are not isolated events; they take us to new places, whether mental or physical. New decisions await us “there,” those forks in the path affected by all our previous choices. In committing once, we also commit to tackling those future questions, whether or not we can predict them.

In medicine, we find a microcosm of life’s questions as we guide people through everything from birth to death. We help patients face complex dilemmas or untangle them ourselves, some but hopefully not all with mortal consequences. Tiffany begins and ends with an affirmation of her agency, concluding “I choose. This I choose to do” (Pratchett 18). Likewise, I too will make difficult choices, because I must. I too will have to learn from them, because I must. I too will have my share of partial victories and failures. While my actions may not have supernatural implications, they will have unexpected effects that reach beyond what I can imagine. Combining commitment with humility, we can traverse medicine’s many uncertainties along with our patients, wherever our paths may take us.

Author Bio: Vishesh Jain is a radiology resident at Santa Clara Valley Medical Center, interested in medical education and using the humanities within his teaching. He obtained an MD with a Certificate in Biomedical Ethics at the Vanderbilt University School of Medicine, where he served as a co-president of Literature, Arts, and Medicine and chief editor of its annual anthology.  Vishesh’s creative pursuits include photography, digital art, and poetry, with themes of nature and symmetry often appearing in his work. Contact Vishesh by email (visheshjainres@gmail.com) or Twitter (https://twitter.com/lifeofsmilez).

Image: Jain, Vishesh. “Shatterglass.” 2016.

Works Cited:

Pratchett, Terry. Wintersmith. HarperCollins Publishers, 2009.

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