Healers, Know Thyselves! A High-Yield Practical and Moral Case for Clinician Self-Knowledge

Audience member: “Do you think jazz music is more for player or for the listener?”
Wynton Marsalis: “Music is always for the listener, but the first listener is the player.”

Medicine has a penchant for repeatedly throwing its practitioners into morally and emotionally challenging situations. We might find ourselves compromising on our own beliefs to protect a therapeutic relationship with a patient, or putting on a face to feign empathy with a family in a situation we are deeply unfamiliar with. We might even be too exhausted to have actual empathy at the end of a long and disastrous shift. What might we do about this? I believe that honing our self-knowledge, particularly the emotional kind, can help. This piece has been written to offer both a practical and moral case for clinicians to do just that.

There have been many reflections on the maxim “know thyself,” famously inscribed into a wall in the ruins of the Temple of Apollo in the ancient Greek precinct of Delphi. In the context of the medical profession, there have been a few of these. For instance, “‘Know Thyself’: Supporting Personal Psychotherapy During Psychiatry Residency” makes a case for psychiatry residents themselves to receive psychotherapy. Another piece is “Physician, Know Thyself: The Professional Culture of Medicine as a Framework for Teaching Cultural Competence,” a medical education piece encouraging physician trainees to look to their own cultures and to explore other cultures to encourage their development as culturally competent healers. Another one is “Physician, Know Thyself,” a very short piece with an accompanying visual algorithm telling medical students to choose a medical specialty suited to their character and behavior. 

My argument for honing our emotional self-knowledge goes as follows:

1. The self is opaque; it is neither completely transparent nor completely inaccessible.
2. The act of getting to know oneself is a skill that can be improved, and can be taught to patients.
3. Self-knowledge, especially of emotions, is beneficial to one’s mental and physical health.

∴ Making the effort to know ourselves makes us healthier and more effective clinicians. 

In medicine, the self being opaque is a not controversial premise. When carrying out motivational interviewing, the opacity of the self is a key underlying assumption – our patients do not have a perfect view into their own motivations and desires. When carrying psychotherapy, we recognize emotions and thoughts as phenomena that need to be explored, and many modalities of psychotherapy focus on building these skills. There is also a large body of literature in psychology meant to teach skills to let us explore this, including the popular Marc Brackett book, Permission to Feel, which examines the importance of emotional intelligence skills and emphasizes how trainable these skills are.

Emotional intelligence as a kind of self-knowledge is a skill associated with improved health outcomes. For instance, it turns out to be a predictor of resiliency in the context of illness such as cancer, helps predict academic performance, and is associated with decreased guilt in substance use disorder patients. Not only does this help patients, it helps clinicians too. As Pruette (2022) points out in “‘Know Thyself’: Supporting Personal Psychotherapy During Psychiatry Residency,” therapists who receive therapy themselves report reduced psychological distress, better self-care, and improved job performance. What medical professional wouldn’t want these benefits?

While the practical benefits of working on our self-knowledge are great, I also want to make a moral case for this. Over 2,000 years ago, writings from the Confucian Analects pointed out something wrong with a disconnect between actual emotion and the ceremonies that were supposed to hone them:

The Master said, “High station filled without indulgent generosity; ceremonies performed without reverence; mourning conducted without sorrow (ai 哀 sorrow)—wherewith should I contemplate such ways?”
(Analects, 3.26; Legge 1960a: 164)

Another excerpt went as far as to compare “mere support” for one’s parents without a deeply held reverence for them as being indistinguishable from the care or utility animals provide:

The filial piety nowadays means the support of one's parents. But dogs and horses likewise are able to do something in the way of support; - without reverence, what is there to distinguish the one support given from the other? (Analects, 2.7; Legge 1960a: 164)x

To Confucians, having values is a central feature of what it means to be human. This is, after all, a humanist philosophical project that could be understood as one which aims to construct a world in which emotions are managed with care, and one in which humanity itself is something that must be cultivated.

As we aim to practice humanism in medicine ourselves, we might feel a similar discomfort if we were to try and help our patients with processing difficult thoughts and emotions in a healthy way if we have never tried to do the same. Caring for patients in such situations without appreciating the moral and emotional depths involved might lead us to feel like we are “faking it” or “putting on a face” and therefore lying to ourselves.

The philosopher Jordan Mackenzie in “Self-Deception as Moral Failure” makes a well-argued case for the idea that lying to oneself amounts to moral failure. Mackenzie (2022) argues:

1. When we are self-deceived, we are always self-deceived about something we value.
2. If we value something, we’re under rational pressure to properly value it.
3. If we’re self-deceived about something, we’re improper valuers of it.

∴ Therefore, if we value something, we are under rational pressure not to be self-deceived about it.

We therefore repeatedly expose ourselves to a moral pressure to not deceive ourselves about our own values. Compassion, empathy, altruism, and humanism – values we often call upon in medicine, therefore risk being violated. In healthcare, this pressure can be external as well – streamers and billboards calling healthcare workers “heroes” were commonplace during the heights of the COVID-19 pandemic.

On the badness of self-deception, Mackenzie (2022) concludes with the following:

Its badness is locatable in the connection that it bears to the objects of our values: rather than striking at random, self-deception infects the very epistemic domains that we have antecedently committed to getting right. This means that we need not look outside the self to locate the moral badness of self-deception; instead, we need only to notice that self-deception involves a failure to properly relate to one’s values, and thus to oneself as a valuer.

If this moral psychology follows, self-deception in medicine induces strain on our very being as valuers – from which arguably stems our very humanity. Returning to the Confucian thinking that was brought up – insofar as being human means having values and being able to manifest those values in the world through our actions, self-deception (especially chronic self-deception) is at odds with what makes us human. I believe that this line of thinking offers a moral psychological framework for thinking about phenomena such as moral injury and burnout.

What are we supposed to do about the feelings this gives rise to? What we do tend to do is suppress these feelings, project these feelings onto others, take these feelings out on others, or cope in other unhealthy ways. One way through is to cultivate ourselves in ways that prepare us to navigate morally and emotionally treacherous waters. What might this look like?

One might take time to get to know our communities and sources of resilience such as religious institutions or community organizations. Perhaps spend more time exploring what it means to be human through media by reading the newest issue of the ARTiculation: Creativity in Medicine journal. Maybe find a therapist to work on our emotional intelligence skills to build resilience and process our emotions in healthy ways. Changing our very situations ought to be on the table as well – residents would be more resilient with reasonable hours, fair compensation, with housing, healthcare, childcare, and transportation needs met. There are many paths to knowing ourselves, and many obstacles as well.

I hope I have raised important questions and concerns with this short piece. It would be fitting to conclude with even more wisdom from the Confucians as to why this matters to not only individual clinicians and their patients, but also to the teams they lead:

If he [a superior person] love good faith, the people will not dare not to be sincere [qing, truthful].
(Analects, 4.25; Legge 1960a: 265) x

The Master said, "Virtue is not left to stand alone. He who practices it will have neighbors.
(Analects, 13.4; Legge 1960a: 265) x

In modern leadership discourses and even within classical Chinese philosophy (particularly from Legalists and Daoists), much skepticism has been placed on the Confucian emphasis on the importance of virtue in leaders themselves. In the context of running corporations, healthcare systems, armies, or states, this skepticism may be well-placed. However, insofar as medicine is a kind of work in which we negotiate with thoughts, feelings, and morality so directly - we must choose to not only hold on to our humanity but lead with it.

References

1. Marsalis, W. (2013, May). Jazz at the Lincoln Center Welcome and One-on-One with Wynton Marsalis. New York City; Lincoln Center. https://www.youtube.com/watch?v=RPsU4DSkvxI
2. Pruette, Megan E. (2022). ‘Know thyself’: Supporting personal psychotherapy during psychiatry residency. American Journal of Psychotherapy 75 (4): 151-153.
3. Boutin-Foster, C., Foster, J. C., & Konopasek, L. (2008). Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Academic Medicine, 83(1), 106-111.
4. Veysman, Boris. (2005). Physician, know thyself. Bmj 331.7531, 1529.
5.  Brackett, Marc A. (2019). Permission to Feel: Unlocking the Power of Emotions to Help Our Kids, Ourselves, and Our Society Thrive. Celadon Books.
6. Rey, L., Extremera, N., & Trillo, L. (2013). Exploring the relationship between emotional intelligence and health-related quality of life in patients with cancer. Journal of Psychosocial Oncology, 31(1), 51-64.
7.  MacCann, C., Jiang, Y., Brown, L. E., Double, K. S., Bucich, M., & Minbashian, A. (2020). Emotional intelligence predicts academic performance: A meta-analysis. Psychological Bulletin, 146(2), 150.
8. Held, P., Owens, G. P., Thomas, E. A., White, B. A., & Anderson, S. E. (2018). A pilot study of brief self-compassion training with individuals in substance use disorder treatment. Traumatology, 24(3), 219.
9.  Boutin-Foster, C., Foster, J. C., & Konopasek, L. (2008). Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Academic Medicine, 83(1), 106-111.
10.  Legge, J., & Ride, L. (1960). Confucian analects, the great learning, and the doctrine of the mean. In The Chinese Classics, 1960a, Volume 1, 164. Hong Kong University Press.
11.  MacKenzie, J. (2022). Self-deception as a moral failure. The Philosophical Quarterly, 72(2), 402-421.
12. For a proper and complete defense of these premises and this argument, I highly recommend Professor Mackenzie’s paper.