Obliging Differences During Times of Pestilence

Operating the better part of a year under the strain from a COVID-19 pandemic, our healthcare workforce continues to undergo significant change — predictably. As healthcare’s predominant and most influential clinical leaders, physicians have generally risen to the situation most admirably; but many in our workforce have also endured significant life-altering challenges. And the pandemic’s imposition in life continues…

The term noblesse oblige refers to the unwritten obligation of privileged people to act with generosity and nobility toward those less privileged. Many people view the medical profession, and by extension those practicing medicine, as privileged. When society is under less pressure and the economy more robust, the profession comes under scrutiny and criticism by many who might contend that physicians do not do enough to fulfill their commitment toward noblesse oblige.

A few things during this pandemic, however, have turned the calloused view of our profession to a more positive one. Appreciation for the healthcare workforce and related allied professionals remains high with an ongoing outpouring of support and public gratitude. People better recognize the essential service medical professionals provide and acknowledge their dedicated commitment to caring for others during times of crisis. The general population has come to understand that without this essential component of society’s infrastructure, a committed healthcare workforce — and with physicians leading care teams — the population would be far worse off. The public views physicians as confident, and their trust in physicians has escalated.

What’s more, the general public better understands that healthcare workers place themselves in harm’s way by working on the frontlines of care during a pandemic. Many workers are also on the frontlines and are at increased risk (e.g., grocery store workers), but none are at greater risk than healthcare workers.

Unfortunately, many healthcare workers have fallen ill during this pandemic and an untold number have died. It will take months (perhaps years) before we have a firm understanding of the magnitude of the negative mental health effects, such as burnout or PTSD. How many of our fellow physicians and our non-physician co-workers have had to change their lives as a result? We likely will never know the true number.

During times such as these, it is not uncommon to reflect on history and philosophy to gain further insights. The Plague, a novel written by philosopher/writer Albert Camus in 1947, is a story focusing on a physician and the people he works with and treats in an Algerian port town that is struck by the bubonic plague.1 This particular work deals with issues central to three different but related philosophies: existentialism, the absurd, and humanism.

Existentialism is a philosophical approach that usually emphasizes the existence of the individual person as a free and responsible agent determining their own development through acts of free will. From Camus’s novel:

“Our townsfolk were not more to blame than others; they forgot to be modest, that was all, and thought that everything still was possible for them; which presupposed that pestilences were impossible. They went on doing business, arranged for journeys, and formed views. How should they have given a thought to anything like plague, which rules out any future, cancels journeys, silences the exchange of views. They fancied themselves free, and no one will ever be free so long as there are pestilences.” (1.5.3)

Similar to those described in the novel, one can argue that during the past several months, many citizens have “fancied themselves free” amid the active pandemic; parallel actions were noted in previous influenza epidemics. Where the balance sits between free will and respect for others in a successful democracy is often a point of significant debate, however.

Being a “responsible agent” for an existential approach, as noted above, is often lost on a few members of our society; specific to the current pandemic, healthcare workers are caught in the crossfire of preferences — at times, to their own health’s detriment.

How should we, as physician leaders, oblige these differences?

Unfortunately, despite knowledge of the ramifications, many in healthcare continue to pursue their own detrimental behavior. When I ask some about their behaviors, they often recognize the absurdity of their actions but proceed, nonetheless. Again, from Camus:

“Throughout the day the doctor was conscious that the slightly dazed feeling that came over him whenever he thought about the plague was growing more pronounced. Finally he realized that he was afraid! On two occasions he entered crowded cafes…he felt a need for friendly contacts, human warmth. A stupid instinct, Rieux told himself; still, it served to remind him that he’d promised to visit the traveling salesman.” (1.8.46)

The need for human warmth and a sense of community can be potentially dangerous during the pandemic, but fear is part of the terror of plague-like conditions. To combat mental anguish, it seems, many people are willing to subject themselves to the possibility of physical anguish, possibly death. There are numerous examples from large-scale gatherings where appropriate safety precautions were ignored and outbreaks inevitably occurred. Many would argue this is an example of absurdity.

“To some, Father Paneloux’s sermon simply brought home the fact that they had been sentenced, for an unknown crime, to an indeterminate period of punishment.” (2.4.1)

Part of what makes any epidemic or pandemic so difficult for people is that often they don’t know or understand why they are being forced to suffer; there is no rational explanation — “that’s just how the world works.” For many, this suffering is viewed as senseless, and it creates deep levels of anxiety and, to some degree, abnormal behaviors compared to their normal routines.

Returning to the subject of physicians and healthcare workers, from my perspective arguably, professionalism is based on the core philosophy of humanism. Humanist beliefs typically stress the potential value and goodness of human beings, emphasize common human needs, and seek solely rational ways of solving human problems.

“If, as was most likely, it died out, all would be well. If not, one would know […] what steps should be taken for coping with and finally overcoming it.

The doctor opened his window […]. There lay certitude; there, in the daily round. All the rest hung on mere threads and trivial contingencies; you couldn’t waste your time on it. The thing was to do your job as it should be done.” (1.5.8-9)

Professionalism is an indispensable element in the compact between the medical profession and society that is based on trust and putting the needs of patients above all other considerations.2 The topic of professionalism is receiving renewed attention as a result of the pandemic, but also because we are in a time of change regarding how to engender a sense of professionalism during all stages of a medical career. A core component of professionalism is obliging differences while caring for others.

And finally, from Camus again:

“They knew now that if there is one thing one can always yearn for and sometimes attain, it is human love.” (5.4.14)

In obliging differences, each of us is responsible for continuing to approach the impact of the pandemic from a humanistic vantage and to draw deeply from our core altruism and belief in people’s inherent goodness as humans.

As we all know, this pandemic will eventually pass, and the resilience of the human spirit will prevail as our entire world accommodates the changes the pandemic imposed. An essential piece of the human spirit is that innate desire and ability to provide and to receive, human love…and to provide love to others less fortunate than we (including animals and other elements of nature as well).

At some level we are all leaders, but being a physician leader is indeed a wonderful privilege that should be honored and cherished; therefore, I encourage all of us to seek and re-define our own sense of noblesse oblige as we continue to move forward while also continuing to oblige the differences imposed on us as a result of the pandemic.

A refreshed culture of optimism for healthcare is possible in the next few years. Leading and creating change is our association’s overall intent. AAPL focuses on maximizing the potential of physician-led, interprofessional leadership to help create personal and organizational transformation that benefits patient outcomes, improves workforce wellness, and refines the delivery of healthcare internationally.

We must all continue to seek deeper levels of professional development and to recognize ways we can each generate constructive influence at all levels. As physician leaders, let us become more engaged, stay engaged, and help others to become engaged. Creating a broader level of positive transformation in healthcare — and society — is within our reach.

Our patients will appreciate the outcome.

INSPIRING CHANGE. TOGETHER.

REFERENCES1. Camus A. La Peste (French). Paris: Gallimard; 1947.2. Brennan MD, Monson, V. Professionalism: Good for Patients and Health Care Organizations. Mayo Clinic Proceedings. 2014;89(5):644–52, https://www.mayoclinicproceedings.org/article/S0025-6196(14)00064-0/fulltext

This article appeared in the Nov/Dec 2020 issue of Physician Leadership Journal.