EP. 148: VIRTUE AND GOOD MEDICINE

WITH JOHN RHEE

Mar 26

WITH JOHN RHEE, MD

A neuro-oncologist and co-founder of the Hippocratic Society explores how brain diseases challenge our understanding of identity, the importance of embracing suffering in medicine, and why caring for patients requires both scientific insight and spiritual presence.

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Episode Summary

There is something uniquely haunting about many neurological diseases. These conditions often don't only affect the body — they reshape the very foundation of who we are, our memories, our personalities, our language. When the brain begins to fail, the boundary between illness and identity start to blur; the person we know begins to fade even before their life has ended.

In this episode, we are joined by John Rhee, MD, MPH, a neuro-oncologist and palliative care physician at Dana-Farber Cancer Institute and Harvard Medical School, whose work sits at the intersection of science, suffering, and the soul. He cares for patients with brain tumors and neurodegenerative diseases, conditions that challenge our deepest assumptions about selfhood, dignity, and what it means to live a meaningful life. Dr. Rhee is also the co-founder and executive director of The Hippocratic Society, a community of clinicians that aims to cultivate virtues that characterize good medical practitioners and ideals that make medicine a sacred profession.

Over the course of our conversation, we talk about suffering — not just physical pain, but the existential kind. We explore how the brain anchors our identity, how its decline confronts us with profound questions, how medical education can improve by training doctors to be more reflective in their work, why an element of spirituality remains critical to medicine, what it means to accompany someone through decline, and more.

John Rhee, MD is a neuro-oncologist and palliative care specialist at Dana Farber Cancer Institute and Instructor of Neurology at Harvard Medical School, where he takes care of patients with central nervous system cancers as an oncologist and their palliative care needs as a palliative care specialist. He runs a supportive care clinic and research program addressing the supportive, symptom, and palliative care needs of patients with central nervous system tumors with the goal of improving their daily lived experience. He was formerly Chief Resident of Neurology at Mass General Brigham and received his MD/MPH the Icahn School of Medicine at Mount Sinai. He is a Young Member of the Pontifical Academy of Life, a bioethics advisory group for the Vatican.
In this episode, you will hear about:
• 3:00 - Dr. Rhee‘s path to medicine
• 6:30 - The general scope of focus for a neuro-oncologist
• 16:07 - Understanding the brain from both medical and existential perspectives
• 26:36 - The mission of The Hippocratic Society
• 40:45 - Why “virtue” is central to the focus of The Hippocratic Society
• 49:34 - How to get involved with The Hippocratic Society
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Tyler Johnson: [00:01:02] There is something uniquely haunting about many neurological diseases. These conditions often don't just affect the body, they reshape the very foundation of who we are our memories, our personalities, our language. All of it lives in the brain. So when the brain begins to fail, the boundaries between illness and identity start to blur. In a very real sense, the person we know begins to fade even before their life has ended. In this episode, we are joined by Doctor John Re, a neuro oncologist and palliative care physician at Dana-Farber Cancer Institute and Harvard Medical School, whose work sits at the intersection of science, suffering and the soul. He cares for patients with brain tumors and neurodegenerative diseases, conditions that challenge our deepest assumptions about selfhood, dignity, and what it means to live a meaningful life. Doctor re is also the co-founder and executive director of the Hippocratic Society, a community of clinicians that aims to cultivate virtues that characterize good medical practitioners and ideals that make medicine a sacred profession. Over the course of our conversation, we talk about suffering not just physical pain, but the existential kind. We explore how the brain anchors our identity, how its decline confronts us with profound questions, how medical education can improve by training doctors to be more reflective in their work. Why an element of spirituality remains critical to medicine, what it means to accompany someone through decline, and more. John, thanks for taking the time to join us and welcome to the show.
Dr. John Rhee: [00:02:58] Thanks for having me, Tyler.
Tyler Johnson: [00:02:59] To start us off, can you tell us what first brought you to the world of medicine?
Dr. John Rhee: [00:03:04] Sure. I had actually wanted to go into medicine for since a very young age. When I was little, I thought about doing work abroad. So initially I was interested in it from a standpoint of wanting to go to a country in the middle of nowhere and and practice medicine there. Kind of serving the poor. And then when I went to college, I had a little bit of a crisis of recognizing that there's many other ways to help people, and that maybe I should try to explore different things, too. So I ended up majoring in policy analysis because I thought maybe public service work could be another way to do that. But doing a year of that type of work, I really enjoyed it. But I realized that my passion was still definitely on the the one on one patient care to accompany people in their suffering. It was around that time, though. I was also reflecting on bigger themes in life that I hadn't really before. Specifically, there was a family friend who had passed away recently, and so I was reflecting on these themes of death and suffering and realized personally that I was really afraid of dying because I thought that both outcomes seemed unacceptable. The idea of potentially disappearing forever seemed really scary, but then the possibility of also like living forever in a different form also seemed really scary. And so it seemed like either outcome was something that was terrifying. And so as I was reflecting on it, I thought that maybe it would be helpful if I were to confront my fear by going and working with people who are dying. And so I decided to volunteer at a hospice over a summer. Part of it was because I wanted to re-explore this aspect of whether I wanted to go into medicine in the first place.
Dr. John Rhee: [00:04:52] And then another aspect was to confront this personal fear. And of course, in experiences like that, you receive so much more, right? And so I worked at the hospice over the summer, and I just had a series of really beautiful experiences. I can remember one woman with stage four ovarian cancer who we were speaking with, and she shared with us the story of how she hadn't spoken with her brother in 20 years, and that she doesn't even remember why they stopped talking. But it was some fight that she feels like was very probably not important. But it resulted in this fight that where they haven't been in communication. And so the work of the clinician there was to talk to her about how she can perhaps rebuild that relationship, knowing that she's on hospice and doesn't have that much time left. And the next time we saw her, she had done just that, and her brother ended up being at her bedside when she passed, which I thought was really beautiful. And so this and other experiences at the hospice didn't necessarily answer the question about perhaps what happens after death, but I thought that it was a really meaningful way to dedicate one's life to to helping people die. Well. And so that was actually what motivated me to go back into doing the kind of pre-med track and going into medicine. So now, right now I'm a neuro oncologist, but I'm also trained in hospice and palliative care, and a lot of what my research and work is in developing supportive care interventions for patients with brain tumors.
Tyler Johnson: [00:06:30] So, so many threads to tug on there. But before we get to some of the bigger thematic threads and also some of the work that grows out of those, which we will talk about more later in the program, I wanted to spend a moment talking about. So you are, as you said, a neuro oncologist. And so as a medical oncologist, I sometimes have to explain to people who are interested in my work that for arguably anatomical, but also also, I think largely historical reasons, there's this funny system. So generally speaking, oncology care is divided into radiation oncology, surgical oncology and medical oncology. Although there is one sort of big exception to that in a way. But then among medical oncologists, the doctors who give chemotherapy, there is one type of medical oncologist who, at least in theory, although this is getting to be less and less the case as oncology grows more complex, but nonetheless, in theory, treats virtually every kind of tumor except that there are these two sort of carve outs, which are gynecologic oncology and neuro oncology. And so those two sort of branches of medical oncology, with the exception I was referring to earlier is that gynecologic oncologists also do their own surgery. But those two branches of medical oncology have sort of worlds unto themselves. So can you just I'm pretty sure that you are the first neuro oncologist we've spoken to on the program. Can you just talk to us a little bit about what are the main kinds of tumors that a neuro oncologist sees, and what does your just your sort of day to day work in that part of your capacity? Not the palliative care part yet, but in that part of your capacity as a neuro oncologist. What do you do?
Dr. John Rhee: [00:08:15] Yeah, sure. And maybe I could talk also briefly about how I ended up doing neuro oncology since, you know, I talked all about palliative care, but then why why am I doing this seemingly random field? Sure, as you could probably tell, I was very interested in some of these bigger philosophical questions since I was reflecting on death and dying and suffering, what it means to suffer, and what the meaning of suffering is, and that continued through medical school. And so I thought that I wanted to just, you know, do internal medicine and do hospice and palliative medicine, and that was going to be my path. And I unexpectedly came across neurology. And so as you mentioned, Tyler. Neuro oncology is kind of an unusual field because usually with oncology you go through internal medicine, you do a med onc or hemonc fellowship. That's how you enter the field of oncology. And you could do that with neuro oncology too, in the sense that you could go through med onc and see neuro oncological cancers. But oftentimes people may do an extra year for getting that specialty in neuro oncology training more because of the fact that, as you said, there's a little bit of these carve outs.
Dr. John Rhee: [00:09:17] So sometimes people don't necessarily feel like they get that much experience with the neuro oncology, oncological cancers, um, the brain tumors in their med onc training. And so I do know of some ONC trained physicians who end up doing a little bit of extra time doing that, or their research is very much in neuro oncology, which is how they end up in the field. But the unusual path for neuro oncology is that you could go through it through neurology rather than internal medicine. And, and I ended up going into neurology because it was an unexpected thing. It was my third year, third rotation, three out of four sections of rotation. So theoretically, for the med students out there who know that the third rotation is kind of the one that you want to do where you perform the best. Right. And that was totally unintentional because I had kind of ruled out neurology, actually, because of the fact that I found the brain and behavior class to be, like, super complicated and confusing, and I couldn't remember the pathways. And I was like, this is not for me. Like, this is for other people.
Tyler Johnson: [00:10:14] You and me both.
Dr. John Rhee: [00:10:15] It was just by pure chance that it ended up in my third block. But you know, I want to be a good doctor. So I was like, I'm going to give my best for all rotations. And I went into it and I loved it. I feel like the patient makes the pathways come alive. And so just seeing like one stroke patient, the pathway made sense to me. And it ended up being the shelf exam that I scored the best in. And so clearly like, you know, there was a change there. And then it felt like what I imagined kind of the traditional doctor to be in the sense that, like my attending, who was really amazing, he's a neurologist at NYU right now, but he's a movement disorder specialist. So movement disorders is especially beautiful in the sense that you depend so much on the physical exam because you don't have that much imaging or blood work or different biomarkers to diagnose the various movement disorders. And he would go into a room. And right before we went into one particular patient's room, I remember we were standing at the computer station, and the patient had kind of wobbled to the door of his room and kind of looked out, turned around, went back in, and this attending was like, oh, he has MSA.
Dr. John Rhee: [00:11:20] And I was like, how did you know that? You haven't even touched him? Like, that's amazing. But there was a sense. And then we went in and he did the exam. And then he explained, like his thought process, clearly he's a very experienced clinician. And so there was an aspect of it where I felt like, oh, this is like what I imagined a doctor to be like, touching the patient, like observing the powers of just being able to, like, have a diagnosis just from like these powers of observation, which I thought was really cool. So that was one aspect. But I think the bigger philosophical question going back to that is that there was a particular type of suffering in neurologic conditions that touches on very deeper, like deep existential questions. So when you lose a sense of memory or you lose a sense of speech or being able to understand it touches on a deep aspect of what it means to be human, because it affects your relationships. It affects on, like, how you understand yourself and your your relationality to others and of course, all illnesses. There's an aspect of suffering to them. And in neurologic illnesses, there seem to be this kind of extra layer of deep existential suffering. And that's been a theme through my medical training, is kind of being drawn to the patients who are especially suffering.
Dr. John Rhee: [00:12:31] And so at the end of the neurology rotation, I found that these patients moved me a lot and that there was a lot of places to grow in Europe. Palliative care. Right. Kind of thinking more deeply about these existential questions, along with the degeneration and also kind of the neurologic conditions are degenerative over time. Right? And there's a lot of fear associated with these two, like ALS, Alzheimer's. And so I ended up going into neurology. And within neurology residency, the neuro oncology part also drew me because there's something special about oncology where you develop deep relationships with your patients, like you become that kind of also in that traditional sense of what one thinks about as a physician, that kind of person that is the go to person for the patient develops like almost like a kind of deep friendship, family like relationship with the patient that I felt very drawn to. So as a neuro oncologist, the most common brain tumors that we see are primary brain tumors, specifically the category of gliomas. And so gliomas can range from like a grade one to a grade four, but in the adult Population most commonly. If somebody does have a glioblastoma, it's detected at the stage of four of glioblastoma.
Dr. John Rhee: [00:13:42] And at this time glioblastoma is not curable. And so from diagnosis, the average life expectancy is about a year and a half to two years. So there's a lot of distress among this patient population. There are also lower grade gliomas. And again usually among adult neuro oncology when one is diagnosed with a glioma then it's an incurable diagnosis. So the question more has to do with how long can you prevent the cancer from coming back? This is kind of the interesting part of neuro oncology where pediatric neuro oncology tumors. So pediatric gliomas behave differently than adult gliomas, even though we put them all under the category of gliomas, where pediatric gliomas. If you have a low grade glioma, they can grow over time, but then they reach senescence. So they just kind of at some point stop growing. And this is an area of active investigation because if pediatric gliomas do that, can we learn from the biology of that to try to then apply it to adult gliomas, which do not stop growing? I mean, they can kind of like freeze for a while based on treatments where they're not actively growing, perhaps for a long period of time to at times for low grade gliomas. But maybe how could we learn from that to apply to adult gliomas? So gliomas are the most common thing, I would say in our practice.
Dr. John Rhee: [00:14:59] We also take care of central nervous system lymphomas. So we are also the kind of main treating providers of CNS lymphomas. So I would say that in my fellowship, those were the the two kind of biggest cancers that we learned to treat. But then we also help. There's a lot of interdisciplinary work, which I think is really interesting because as the cancer population ages and there's more treatments, including targeted treatments, there are more and more patients who have brain metastases. And so at this time, a neuro oncologist isn't the one who actually treats the brain metastases in the sense of like not giving chemo or targeted therapy, etc. for the brain because that's for the medical oncologist. But at times when there are things that are fairly complicated and require a interdisciplinary approach for surgery, radiation, medicine. Thinking about systemic things, thinking about only progression in the CNS, there has been an increasing role of the neuro oncologist, where the neuro oncologist helps with coordination of that. But then also neuro oncologists are starting clinical trials, especially where metastases are progressing only in the CNS, in which case sometimes the neuro oncologist may be playing a more active role there.
Tyler Johnson: [00:16:07] You know, just to briefly mention first, and then I want to go back to one of the philosophical things you brought up. But it is really interesting as a I'm a medical oncologist who treats patients with GI cancers, GI cancers actually quite rarely go to the central nervous system. It does happen, but it's unusual. Unlike in breast cancer or lung cancer, where it happens all the time. But it is interesting to me that when I have patients whose tumors go to the central nervous system, I almost always involve neuro oncology, partly. And I tell this to my patients because at least in the case of GI tumors, tumors that have traveled to the central nervous system, it's almost like the person now has two cancers, because whether this is true or not, but we often think about what we call the blood brain barrier, right, in physiology, which is to say that the body, understandably and seemingly purposefully, has sort of walled the central nervous system off from the rest of the physiologic system to try to keep it quarantined and protected. Which is to say that I have literally never seen something that I have done, even chemotherapy that works well in the rest of the body. In the case of GI tumors, at least, virtually never does anything in the central nervous system. And so anatomically, physiologically, that that can be really challenging. Maybe that's actually a metaphor in some ways for this other point that I wanted to bring up in reflecting on part of what you said about the sort of the difference in treating patients who have neurologic disorders.
Tyler Johnson: [00:17:30] I have a Substack, and part of what I write about in my Substack is some of these sort of involved philosophical and existential and religious issues. And one of the things that I have an essay that I've been working on there that I have been thinking about is the fact that anybody who has been through an internal medicine residency, or even through medical school, will know that we often talk about terms like liver failure, kidney failure and heart failure. Right. And anybody who's been on an internal medicine rotation will be able to go through and say, oh, well, if you have a patient who's in heart failure, they'll have these symptoms. And if you have a patient who's in liver failure, they'll have these symptoms and this is how you address them. But in all my years working as a doctor, I have never heard anyone use the term brain failure. Right. And in some ways, actually, that does us somewhat of a disservice because it adds this kind of an existential weight to neurologic and especially psychiatric problems. That doesn't need to be there. Right. It makes them seem volitional, or it makes them seem as if they have this kind of a, like a moral component to them. Right. So that if some. So in other words, someone who's suffering from a psychiatric disorder, we often impute to them that they're choosing not to try hard enough or in some cases less so now than previously.
Tyler Johnson: [00:18:48] But in some religious systems, we even impute to them sort of a moral valence, like they are like, it's not just you're not just sick in the way that you're sick if you have a heart attack, but you are sick and bad or evil or wrong or something, right, you are possessed or what have you. Where this becomes most apparent is when the way that we talk about people who die by suicide. Right. Even the the the way that we often have traditionally phrased it, they have quote unquote, committed suicide. It is as if we understand some outcomes of psychiatric and neurologic problems as crimes rather than as diseases. Right. And the thing that I think is just so interesting about all of that is that on the one hand, there's a sort of a pastoral part of me that wants to say, no, no, no, we can't do that. But then at the same time, there is also a philosophical or psychological part of me that recognizes that in a way, I'm not trying to defend doing that, but but I am trying to defend our impulse to understand that something about the brain is just different, right? Because if you divest it of all moral or existential or whatever elements, and try to treat the brain as if it were somehow equivalent to a kidney or a heart, like unless you are just a genuine like dyed in the wool, hard core root and branch determinist who believes that everything is just the functioning of random neurons, and we have no say about what we do ever like.
Tyler Johnson: [00:20:17] Some intuitive part of us knows that a brain is not like a kidney, right? Like, I was really struck when I read Yuval Noah Harari, Homo Deus. Yuval Noah Harari is this pretty hard core? I don't know if he would consider himself a determinist, but he's a pretty hard core reductionist, right? He believes that sort of we are our biology. But even in that book, he recognizes that we have absolutely no idea, in effect, what's going on with consciousness. Like, for everything we understand about human physiology, we just don't really even know what consciousness is, which is just to say that that sort of and arguably, I don't know if it's the biggest, but certainly one of the biggest sort of gaps that remains in our understanding of human physiology is how do you bridge the difference between the brain and the mind, right. Like, how do you make up the difference between what we understand to be the firing of neurons in the physiological brain and what traditionally we have called the soul, right. And it seems like we do have to leave some room for mystery and for existential weight there. Otherwise, we end up in a place of pure reductionism that, while it might at first seem sort of pastorally comfortable, I think ultimately doesn't really satisfy what we understand needs to be there.
Dr. John Rhee: [00:21:29] Yeah. I love all those reflections, Tyler. And yeah, just as perhaps a joke, the other day I was talking with a cardiologist who was arguing that the heart was the most important organ in the body, and I was like, clearly it's the brain. So. But but I do think that there's objectively something different about the brain, right? And the way that we think about it. And part of it has to do, I think also with the evolution of how we understand a more, maybe metaphysical question of what it means to be human. And so there's been a movement away from understanding the person as this body, soul, composite whole, this hylomorphic whole, right towards this more dualist understanding that the body and the mind are separate things, or the body and the soul are separate things, and therefore that has impacts on like how we think about the mind which kind of interacts with the body and the soul, right? And so when we think about it in that way, our modern understanding is that we are what we think, right? So we define ourselves purely by. Yeah. So I think therefore I am right. This idea that we are defined purely by our cognition. And I think that it's just important to know that this is a newer philosophical trend, right, post enlightenment, but also that this has impacts on how we think about patient care.
Dr. John Rhee: [00:22:51] I just want to say like briefly, that this is the work that we're doing in the Hippocratic society, which is to reflect more deeply. This is a nonprofit that I founded to help physicians think about what it means to pursue the good in medicine. But oftentimes, as physicians, we may think about these philosophical questions as like, oh, very theoretical. But in this case, if we think about our cognition being the pure factor in which we define ourselves, then once somebody loses cognition, then they are no longer then worth living, right? So there is like a fairly dramatic impact right on like how we're understanding them, what it means to be human. And it impacts us because as physicians, we are taking care of these patients. And if that is the, I guess, philosophical framework that we accept, and I think it is implicitly right. I mean, if we just reflect on the fact of taking care of our patients, that there's a sense in which, you know, I overhear oftentimes clinicians saying things like, oh, this patient with Alzheimer's, like, I mean, they're suffering. Maybe it's like, better not to like do XYZ or there's like, there's a difference in their care when their cognition is affected. Right. And so I think it's important just to be recognized, like where our philosophies develop and how they impact the way we care for patients.
Dr. John Rhee: [00:24:06] So just like one perhaps thought to throw out there for people to reflect on. But the other thing that I think is really interesting is that as a both a neurologist and a palliative care physician, that you're exactly right, that there's so much that we don't understand about the brain. And so just the other day, I was reflecting on this as I was going into a patient's room with delirium. So it was a neuro oncology patient with delirium and delirium super common in the hospital. Like 25% of hospitalized patients have delirium, right? Also a kind of syndrome that we don't really understand what's going on, despite the fact that so many people experience it. We have like, not really evidence based ways of treating it. And then as physicians, we all know that the most common way we treat it is like throwing these like dopamine antagonists on these patients, even though we know that like the labels say, that that could, like increase the risk of death and all these things. Yeah, right. Exactly. So anyway, it was just like a syndrome that we have a hard time treating. And I think delirium is like a really interesting thing because though I just said all of that, the one thing that everybody knows, like all clinicians know is that somehow patients do like so much better if their loved one is with them in the room like that, they're present with them.
Dr. John Rhee: [00:25:20] I mean, isn't that just like, so interesting in the sense that this person's cognition is like totally off? They're like paranoid. Oftentimes if the delirium is severe, like paranoid, trying to get out of bed, like attacking people at times because they're afraid and not knowing where they are, etc. but somehow when their cognition is, despite the fact that it's like something is like totally off inside their mind, the presence of a loved one survives through that. Like there is a bond that exists despite the brain malfunctioning. And I think it just speaks to the fact that there's like mystery here. I think of the fact that we don't understand what's happening in the brain and that if we are just have like a materialist approach of like the brain as a kind of physical organ like that, it's like functioning just based on neurons. I feel like anybody who falls in love even would say that that's not how love works, right? That it's not just like neurons firing. Right? And so I think, yeah. And I think delirium is like a really interesting example of a syndrome that we all know. And we all know that there's something different about the way in which patients with delirium do so much better that survives through this, like bond with relationships. That's not just like cognitively based.
Tyler Johnson: [00:26:36] Yeah, I think that's a really lovely distillation of the idea that that gap between the, you know, it's really striking if you are a medical student and you've been through gross anatomy or neuroanatomy and literally held a person's brain in your hands, right. Like on some level, the brain, of course, does exist as a physical, palpable, heritable thing, right? That has this kind of like pinkish, spongy consistency to it. But then, on the other hand, the gap between that thing that you can hold in your hands and everything that we know about the neurons and synapses and neurotransmitters and whatever. And as you put it, the fact that it can somehow fight through its own fog to recognize, you know, the person's spouse of 50 years or their brother or sister or mom or dad or whatever. I think that's a powerful testament to the fact that the body as a whole, but the brain in particular, resists this completely materialistic, reductionistic approach. Right? Like, it would seem that we are more than just our atoms. But let me. Although we could spend the entire hour talking about that.
Dr. John Rhee: [00:27:42] Yeah. For sure.
Tyler Johnson: [00:27:43] So you mentioned briefly a minute ago this thing called the Hippocratic Society, which you have founded and which I have now attended multiple events of the Hippocratic Society. We have a chapter here at Stanford that was opened a couple of years ago. So before we get into the why of it, I'd love for you to just talk to our listeners about what is it and what does it look like if you, you know, if some listener somewhere wanted to open a chapter where they are like, what would that mean and what would the chapter do? Yeah.
Dr. John Rhee: [00:28:15] The mission of the Hippocratic Society is to form and sustain clinicians in the practice of good medicine. And so sounds like a very lofty goal, maybe even a vague goal. But I think the perhaps more interesting thing is like how we do that, right? What is happening at the different chapters. And so what we were trying to do is that and perhaps this is a little bit of a commentary on education as a whole.
Tyler Johnson: [00:28:39] So trust me, we've gone there on education.
Dr. John Rhee: [00:28:42] So so, so hopefully I don't say too many like controversial things, but but no, I think it's not controversial in the sense that there's a sense in which overall higher education has moved more and more towards perhaps a knowledge based education. So and I think we've gotten very good at that. Like, right, teaching students how to think about the biology of things, teaching people how to be evidence based, teaching people how to really, critically read a document and question as to whether it was designed well, etc. but I think that for various reasons of changes in also like I think some of these philosophical, metaphysical questions, higher education has moved away from any type of what one could call like moral formation or moral education of students. And I always think that this example is indicative where, you know, we all know for our undergraduate institution that we went to, there's the alma mater, right. And so that's the song that we sing, that kind of it's the nostalgic song that reminds us of our time at the university. And alma mater is Latin for soul of the mother, in the sense that the idea behind it actually is this idea in which the university was a place in which one was formed, not just intellectually, but humanly in the virtues and also spiritually. Right. And so there's a sense in which the formation was full, that one was not just learning to be an intellectual person, but one was learning to be what it means to be a good person.
Dr. John Rhee: [00:30:14] And what what does that mean? I mean, there's many things that that could mean, but that was a main part of the aim of education was to reflect together on what it means to be a good person, and therefore also be a good person in the middle of society. Right. And so medical education, I think, has been impacted by this movement of higher education as well, where there has been a removal of any type of. One could say like moral formation of physicians. But I think the, the consequences of that in medicine are much greater because we are treating another human person. There is no way to separate out morality from that, even from the examples that I just gave our own understanding of. Like what it means to be human affects directly our philosophy of like therefore, how we take care of a patient and whether the patient in front of us is alive or not alive, or whether their life has meaning or no meaning. All of these questions are actually larger questions. Moral questions. One could say that they're directly impact how we care for patients. And so I love the medical school that I went to. And I will say that all of our ethics courses did not cover these types of questions. Questions like, what does it mean to be a good physician? The idea of physician identity formation. Like, what does that mean? What does it mean to have like a relationship with a patient? And what does it mean to like be a virtuous physician? Right.
Dr. John Rhee: [00:31:40] So when we talked about ethics, typically we talked about it in the context of a legal framework. Right. So like these are professionally things you shouldn't do because legally that would put you in a bad place. Right. And so ultimately it was like from this perspective of a legal lens. And of course, like all medical students, there was the introduction of the Principlism model. Right. The four principles as kind of this like framework of ethics. But then like it's not really taught to you, like how to apply the principles as a model in the sense of like, how do you balance the four principles in a way, in a particular circumstance for a particular patient, because it's presented as four principles that are perhaps equal weight, but perhaps autonomy is most important. And so it's hard to know how to actually like apply this ethical model in our practice as well. And the fact that there are many other ethical models, many other models of how we understand the human person and also reflect more deeply on physician formation and identity formation. And so the idea of the Hippocratic society is to come together in groups, local communities. And it takes a kind of traditional model in the sense that medicine has always been an apprenticeship. And so we gather at the home of an attending and we eat dinner together. So we have a meal together.
Dr. John Rhee: [00:33:08] So it creates this environment in which people can be open. And there's an aspect of inviting people into one's home that makes it more familiar, welcoming. Right. What happens in those dinners is that we have a series of dinner discussions based on a variety of topics, but aimed at reflecting together as a community on how we could grow in terms of being better physicians or good physicians. So a lot of the framework of what we use is morning Report style, in the sense that we have a case that revolves around a particular moral question, and we use that as a framework to then discuss our own experiences. And then we always try to end the session by reflecting together on how we can grow in that particular question that we're discussing. So, for example, this past Friday, we had our discussion at Harvard, at our Harvard chapter here, and we had a discussion on a case specifically around the topic of self-effacement. And so self-effacement has a virtue combining the idea of humility and why humility is important in medicine, but also a rich discussion on there's an aspect of self-effacement where at least a question of in self-effacement, of how much does one, as a physician, sacrifice one's own life for the patient, or at least one's own kind of interests for the patient? Right. And so there's a lot there. Because actually, just a few weeks ago, there was a Wall Street Journal article about this idea that the current generation of medical students see medicine differently in the sense that they want to see it as more of a typical job, like have typical hours, like be out when they're done.
Dr. John Rhee: [00:34:50] And there's like this distinguishing of like, is there something innately different about medicine as a profession where there is this aspect of sacrifice. Now, I think that that's so interesting because conversely, at the beginning of the Covid crisis, when we first had Covid here and people were dying, people were on ventilators, etc., that year was the highest peak in applicants to medical school. And I think that that's really interesting because people were clearly sacrificing their lives for people like. So people were like in these places, like without proper PPE, like I remember as a neuro resident, I was both working in the Covid ICU, but also was doing stroke consults and like I would like run, go evaluate a stroke patient and then like and didn't have like yet the N95 mask at the time because it was just the beginning. And then like getting the kind of alert later that I was exposed to Covid and that at the time we knew very little like more severe strains for patients in ICU, etc.. Right. That there was a lot of fear and a recognition that like what we were doing potentially was consequential in the sense that there were also some young people that were like dying and also had Ards and like severe consequences from Covid.
Dr. John Rhee: [00:36:01] Right. And so I also think that it's interesting that there was such a huge spike in medical school applicants that year, because I do think that it touches on a deeper desire that I think is a aspect of the human condition where one sees this beauty in self-sacrifice. I think we see it in very individual aspects of things like relationships, marriage especially, I think, being the key one, where one sacrifices one's life for the other in the sense of one's like, including preferences or things they might want to do. When I talk to friends who are in this stage of figuring things out with marriage, there are big questions about like moving across the country for their spouse. I mean, these things that like one didn't ever expect perhaps to be doing, but then now is like they're in a totally different place because this is like what one does in marriage, right? And there's something very, I think, beautiful about the profession of medicine where and it's not it's not just medicine. I think also like clearly nursing falls in this as well, where there is an aspect in which part of the profession is that we are in a position of authority or power over the patient, right? And that as part of that relationship, there's also an expectation that we are also sacrificing for our patient. But again, like part of this current movement of desiring a more like normal work life balance with medicine, which I also think is coming from there, are there a good kind of things that that's coming from? You know, I also worked like the 28 hour every four day shifts in residency.
Dr. John Rhee: [00:37:35] And I also think that there's an aspect of reflecting on then like, how does one find the right balance there? Then I think that that comes with this virtue of practical wisdom, because it's not even just uniform, right? Like, it may look a little different if you are pregnant, right? Because how you're working in the hospital, maybe you change things because you recognize there are sacrifices also in your own life. You make for your family, etc.. Right? And there are maybe stages in one life, one's life where that looks different too. And recognizing that that's the case and this is all like of what we do in the society, is to reflect together on like, the ways in which we could grow to be good physicians together as a community and therefore sustain and support one another, and then also reflect on these bigger questions in medicine that I think have always been there, but that in the current, perhaps medical education environment, there is not as much opportunities to be reflecting together, especially with those who are much more experienced, like attendings and also those in training for for many years and for medical students to also be exposed to that. But then there's also this beautiful thing that I think happens in these discussions where the other day Today.
Dr. John Rhee: [00:38:47] We were having a discussion in one of our discussions on that, on the virtue of hope. And so we were talking about hope as a virtue and within the patient doctor relationship, and what the role of the doctor is to kind of transmit hope to the patient, especially if there's maybe like no treatments left and what does that look like, etc.. And it was kind of funny because there were two cases. One was about a patient feeling hopeless in the context of like having no more treatments and like what the role of the physician is. But that was ended up being the second case. The first case was this resident who was working in the hospital, and it's like late at night and they wanted to like get out on time and they have a medical student with them. And then this, like, patient comes in like five minutes before the end of their like kind of time for taking new consults, new admissions. Who is this like patient who like always comes in, you know, with like another heart failure exacerbation with COPD. And and it was reflecting on this idea of like hopelessness of medicine itself and what kind of how 1st May fall into that in training. And it was funny because that particular session there happened to be a lot of preclinical medical students who were participating and they just like, didn't understand the first case, but I thought that was like, great. They were like, well, I don't understand why.
Tyler Johnson: [00:40:04] What's the question?
Dr. John Rhee: [00:40:05] What's the question like, why is that hard?
Tyler Johnson: [00:40:07] Why is that? They're like, oh, just you wait. Just when you tell that story, there is this like deep part somewhere inside of my bones that can just, like, feel the ache, like, oh, another three hours to write the happy like I cannot.
Dr. John Rhee: [00:40:27] Yeah, exactly. When I talked to, like, attendings who have participated in it, too, there's a sense in which they also get a lot from the kind of preclinical students, too, of renewing the sense of like, ideals and this kind of idea in which they came into medicine. And I think that that's also helpful, too, for for those who are, I guess, more experienced.
Tyler Johnson: [00:40:45] You know, when you're reflecting on the larger state of education. We've talked about this before, but it's been quite a while on the program. But one of my very favorite, just because I think it's so telling about the state of education, and actually I think about the state of society in a lot of ways in the, you know, early part, I guess, of the 21st century is that now, almost exactly ten years ago, William Dershowitz wrote this article in The New Republic, which then he later parlayed into his book Excellent Sheep. And he makes the argument that even though the Ivy League schools and others like them are vaunted as these sort of, you know, places where we send our best and our brightest. His argument is that what actually happens at the Ivy League and other places like that is that we train what he calls excellent sheep, which is to say that we have people who, yes, have incredible native abilities. But in effect, what we do is we teach them to jump through this very complicated and specific set of hoops, and they come to do that really, really well. But his argument is, I'm not saying that this is necessarily true, but his argument is that there's sort of no there there that they just kind of are going around and doing the things and this and that.
Tyler Johnson: [00:41:53] But there's no like deeper soulful substance to the education. They're not asking deeper questions. They're not engaged in what he calls making a soul or making a self, rather, not a soul making a self. And what's really interesting to me is that then Steven Pinker, who's this world famous Harvard psychology professor, responded to the article in writing, and I'm going to quote this is part of his response. He says. Steven Pinker says, perhaps I am emblematic of everything that is wrong with elite American education, but I have no idea how to get my students to build a self or become a soul. It isn't taught in graduate school, and in the hundreds of faculty appointments and promotions I have participated in, we've never evaluated a candidate on how well he or she could accomplish it. I submit that if building a self is the goal of a university education, you're going to be reading anguished articles about how the universities are failing at it for a long, long time. And the thing that's so interesting to me about that is that, you know, if you're having a certain kind of conversation about problems with American education and problems with wider society, there's a sense in which it feels like Doctor Pinker is sort of saying the quiet part out loud, right? Like, it's it's not just this sort of like, well, okay.
Tyler Johnson: [00:43:19] Yeah, maybe we could do a little bit better. There might be a little bit of a point there. You know, it's almost this, like, bravura, right? It's like this. Well, duh. Yeah. What would we do that for? Right? Like, there's not even a countenance that it might matter. Right? And so I think in that sense, the thing that from the Hippocratic Society meetings that I have been to, which is, you say, you know, meetings almost feels like a formal term for them in a sense, because it's, you know, it's literally like you go over and you eat dinner and then you have a conversation, right? But the thing that has been so striking to me about those, probably the single most striking facet of them, is the insistent and very open focus on the term virtue. Right. So the meetings and you sort of alluded to this, but there's a centrally prepared handout that is then sent to each of the chapters, and then the chapters use that it has the case on it that you mentioned. And then and then it has some prompts for discussion or whatever. But the thing that is so interesting to me about those is that the prompts for discussion and the case and all of it, each meeting is centered around one virtue, or at least a virtue based question, sort of depending on the specific one.
Tyler Johnson: [00:44:32] But the thing that strikes me so much about that is that that's kind of like, I don't know your old Uncle Herbert's sweater that you go get out of the attic like nobody talks about the word virtue anymore. Like, that's it's, like, anachronistic. Almost, right? Like. No. Like it's just not a I mean, I feel like we live very much in a. I actually learned recently that apparently the 1970s were dubbed the Me decade, which really surprised me because I would have thought that was the 2020 standard. Right? Like the, like, larger philosophical, often unstated, but like the ethos I feel like is you do you? That's kind of the catchphrase, I feel like of the dawning century is you. Do you or your truth, as people famously talk about, right? Like, the idea of virtue just almost feels like an idea whose time has passed. And so I guess I'm curious, and you've referenced this a little bit with your discussion about sort of educational philosophy and whatever, but how did you guys come to the determination that, of all things, the kind of Operational fulcrum of the entire enterprise would be a focus on virtue.
Dr. John Rhee: [00:45:39] Yeah. Great question, Tyler. And there is a comeback. I think maybe this is like a biased view, but a virtue and virtue ethics in the sense that, you know, virtue ethics was a very widely accepted philosophical approach to life that starts with Aristotle or mostly with Aristotle, who wrote the Nicomachean Ethics and talks about what it means to live basically a flourishing life. Right? He talks about this idea of arete, or moral excellence, and to live a happy life, a life full of meaning. He argues that one has to live the virtues in order to flourish, right? And this continues over the years being developed, I would say Thomas Aquinas, also big virtue ethicist in the sense that he developed a lot of the ideas of what it means to live out specific types of virtues, Especially focusing on the theological but also the cardinal virtues. And then you're right that there was a little bit of like some period of time where there was a dormancy in virtue, and a lot of people thought of it as like something like from the olden days, like, why should we talk about this? But I think in the last half century or so, there has been a resurgence in virtue. And so even if you like, do a search on PubMed or also like humanities journals, there has been a refocus on this idea of flourishing.
Dr. John Rhee: [00:47:04] So what this what it means to live a meaningfully and also flourishing life. Right. And it's applied not just to kind of the traditional topics that Aristotle talked about, which was very individual in its approach to virtue in the sense of like, how do I as a person grow in this particular virtue? And therefore what are the practices that one has to live in order to be a virtuous person in order to then also live a fulfilling life. Right. I think that the developments in the last 50 years, to me, bring that further in a very beautiful way. And what I mean by that is that there's been a growth in this idea of community virtue or communitarian virtue, this idea that virtue is not just like an individual growth, but actually can be shared among people. And that community can be a way in which we grow in virtue together, which is the basis. So this work of Elizabeth Anscombe, Alasdair MacIntyre, that brings this into perspective of how the community and our role in that community, but also our dependency on one another. So this dependency on on each other as what it means as a core aspect of what it means to be human and to recognize that is really important in what it means to like, understand ourselves. And so this is kind of the theory behind what we do in the society, in the sense that we are coming together as a community, recognizing that it is discussion through support and this community that we could actually grow in virtue together, that there is obviously an individual aspect of it where virtue has to be practiced for one to grow.
Dr. John Rhee: [00:48:41] So if you're trying to live, for example, humility, well, in the hospital, then you know, as a, for example, as a resident, how can I grow in the way in which I explain things to medical students with humility? Or how can I take criticism from attendings in a way in which I truly grow, rather than only, like, push back within myself, recognizing that ultimately that is all for the good of my patients too, right? So it's not just making me a good person, because it helps me be more self-reflective on the areas of my weaknesses which I'm blind to. But also, if I receive criticism, well, then I grow in becoming a more competent physician. That also helps my patients. Right? And so there's individual aspect of growth in the virtue that's necessary to be a good physician. But then also this developing idea of virtue that's grown in community. That is, I think, core to the kind of theory behind what we're doing in the Hippocratic society.
Tyler Johnson: [00:49:34] Yeah. So I don't know that I've ever we've ever had someone on the show where as a result of having them on the show, I've encouraged people to go and do something. But I will say that I think, you know, based on my experience with these meetings and the nascent program here at Stanford, I think this is a good and open project. I think that it's a project that can add a dimension to our medical education. That, to your point, is arguably lacking. I think to be clear, the philosophical grounding of the Hippocratic society is not specifically religious or grounded in any particular philosophy or set of ethics, but it is rather the idea that the inculcation and cultivation of virtue Matters. And to that point, I love this quote from so many years ago. Nearly a century ago, C.S. Lewis wrote a very short book or gave a talk everyone to talk about it, about the, in effect, the importance of recognizing absolute good in the way that we educate others, and commenting on what he saw as a drift away from that grounding idea.
Tyler Johnson: [00:50:47] He wrote at that time, this is in a book called The Abolition of Man. He said, in a sort of ghastly simplicity, we remove the organ and demand the function. We make men without chests and expect of them virtue and enterprise. We laugh at honor and are shocked to find traitors in our midst. We castrate and bid the geldings be fruitful. And I think that's a really sort of a forceful articulation of the reason that virtue matters, and the reason that seriously grappling with it and thinking about it and taking on the task of trying to make ourselves more virtuous is important. And so to that end, why don't we finish by? Can you tell if there are people who are listening and wherever they are, either as attendings who are doing medical training or people who are going through their own medical training, and they thought, oh, I'd really like to look into this. This sounds like it could be a cool idea. What would they do if they wanted to start something like this, wherever they are?
Dr. John Rhee: [00:51:50] Yeah. Thanks so much, Tyler. And I agree with everything you said, summarized so beautifully that yeah, we're not like we're not based in any philosophical or religious tradition. And I think that's been the one of the the aspects of the discussions that's been very rich is that there are people from all different backgrounds who contribute to this, and I think that there's still a sense in which everybody knows that, you know, living courage is good, because then we will stand up for if there's some mistake happening to a patient that we won't be worried or that it might be hard, but that we will, like, rise up to say something if we're cultivating this virtue of courage, for example, or fortitude. So it's clear to people, I think that virtue is important, whether you're calling it virtues or whether you're calling it perhaps like ideals, but that there is a sense in which these are important for what it means to serve our patients well. And so the way to get involved is, well, I would love to hear from people. We have a website for the Hippocratic Society. So if you Google Hippocratic society but also hip sock. Org. Org. We have a website. It's still fairly new, so there's not like too much there, but at least you could see the background of what we're doing. Different chapters involved contact information. We also have a podcast that's fairly new called The Hippocratic Society.
Dr. John Rhee: [00:53:05] And how it's organized is there's like a longer form podcast covering some aspect of a philosophical topic or kind of physician identity formation, and then a part two of that where there's a shorter one of 10 to 15 minutes talking about a particular virtue and how one could implement growth in that virtue in one's life within the context of medical practice. And the idea behind that is to kind of couple a practical part with a more philosophical part, to then kind of integrate that into one's life, to try to grow in that, especially for people who may be at a place where we don't yet have a chapter to be able to start some of that work on, on one's own. And so we'd love to hear from you. We have an email contact at org that we actually have been getting a lot of requests from. And so usually it's people that reach out. And then we kind of also reach out to our own networks and see who else might be at the place you're at. And then we have a framework for how to start having these discussions. And it could be as few as like five people coming together for the first discussion and then over time, growing it so that there could be potentially even groups at a particular institution if it gets big enough in order to have those more smaller, intimate conversations.
Tyler Johnson: [00:54:17] Yeah. So and we will put links to those things in the show notes. And we really appreciate you being on the program. And thank you for joining us on the show.
Dr. John Rhee: [00:54:26] Thanks so much for having me, Tyler.
Henry Bair: [00:54:31] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show. Available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:54:50] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:55:04] I'm Henry Bair.
Tyler Johnson: [00:55:05] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.