Heart at work: Professionals who care

October 2, 2007

On January 10, 2002, a healthy 57-year-old man underwent a liver donation procedure that successfully resected approximately 60 percent of the right lobe of his liver in preparation for transplanting that liver into his brother, a 54-year-old man who suffered from a degenerative liver disease. After what was described as a technically uneventful transplant, the donor patient seemed to do well on the first postoperative day. He began to manifest some tachycardia, abnormally rapid heartbeat, late on the second postoperative day. Early on the third day, he began to hiccup and complained of being nauseated. He was given symptomatic treatment. Later that day he began to vomit brownish material. He became oxygen-desaturated (lacking adequate oxygen in the bloodstream) and was placed on 100 percent oxygen by mask. He was pronounced dead on that third day.

Three months later, the state health commissioner issued an incident report that said, “The hospital allowed this patient to undergo a major, high-risk procedure and then left his postoperative care in the hands of an overburdened, mostly junior staff, without appropriate supervision. Supervision of medical residents was far too lax, resulting in woefully inadequate postsurgical care.”

I do not doubt that the hospital, inadequate staffing, inexperience and lax supervision are all to blame. I do not doubt the importance of identifying and fixing these system problems. But I am struck by the abstract, impersonal quality of this language, as if no one involved had a name. This analysis assigns culpability not to people but to nouns: hospital, staffing, inexperience, supervision. When systems analysis is our only approach to a catastrophe of this sort, it becomes one more way that we allow the logic of institutions, which is about self-preservation, to overwhelm the logic of the human heart, which is about love and duty. In the process, systems analysis can contribute to the long-term decline of compassion, responsibility and courage in our culture.

As I read the case study, trying to bring it down to human scale, two details caught my eye. First, at the time of the donor’s death, a surgical resident with only 12 days of experience in the transplant institute had been left alone to attend to this man—along with 34 other intensive-care patients—during a critical three-hour period when the donor developed serious symptoms. Clearly, the resident could not give her charges the attention they required. She later described herself (in what must be an understatement) as “feeling ‘overwhelmed’ by the responsibility of caring for so many patients.”

Second, the donor’s wife was at the hospital during the entire postoperative period attempting to advocate for her husband. Her description of his final hours is heart-wrenching: “I was present . . . while my husband coughed up blood for two hours before he finally choked on it and died. [I] begged for attention to his condition and got none.”

I think often about this woman and the nightmare she endured, a nightmare she lives with to this day. I think also about the young resident who was abandoned by her colleagues during that critical time, and I have empathy for her as well. Surely she was left with a nightmare of her own. But a moral response to this catastrophe ends neither in personal empathy nor in the penalties the New York State Health Department imposed on the hospital. We must ask how medical residents might be educated to confront institutional inhumanity of this sort instead of collaborating with it through action or inaction. If that question were answered, it might go a small way toward redeeming the suffering of all involved—the man who died, those who loved him, and the health-care professionals who have accepted the burden of responsibility for his death.

Surely this resident knew that the system was collapsing around her. As she rushed frantically from bed to bed, she must have been aware of the human cost that might be extracted from her patients, their kin and herself. What kept her playing her role as an obedient underling in this tragedy instead of speaking truth to power? What kind of action might she have taken to bring reinforcements running? Is there a moral equivalent in the workplace to sending up flares, sounding the alarm, blowing whistles, raising holy hell? And what does it take to act this way in the moment, while there is still something to be salvaged, instead of waiting for a review board to ask what went wrong?

Of course, we might view the resident as another victim of the system, the pawn of superiors whom she could not confront because they had power over her career. That is how many of us excuse ourselves from workplace lapses of morality. But if we give her a moral pass on these grounds, we fail to honor the heart of the healer in her, to say nothing of failing to honor the man who died and the family and friends who must go on without him. Not just the system failed in this case. The heart of the healer failed as well, a heart that surely knew what was occurring but refused to recognize the fact.

What caused “heart failure” in this resident, apparently leaving her with the sense that she had no option but to play the stacked hand she had been dealt? Can we think of her not as a victim but as a moral agent uniquely positioned to challenge and help change the institution before, during and after the moment of crisis? If so, what might happen in residency programs to support the healer’s heart—and the courage to follow it—when the conditions under which medicine is practiced threaten the heart’s imperatives? And how can questions like these be asked about education of every sort, at every level, as we prepare students to work in institutions that so often prove toxic to their deepest values?

Let that medical resident serve as Exhibit A in my case for educating a “new professional,” by which I mean a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards. I know of no field where the new professional is not needed. Medicine may capture our attention because institutional deformations can lead to the high drama of physical death. But deaths of other sorts are everyday events in most professions. The life chances of poor children approach zero when school systems are more responsive to the rich and fail to encourage and support good teachers who are dedicated to educating the poor. Clients seeking simple justice find that money, not law, is the best defense, and lawyers who want to devote themselves to pro bono work find it difficult to sustain their vocations. Clergy who want their faith communities to side with the dispossessed sometimes find that their goals, and souls, are thwarted by institutional demands for members and money, that they are pressured to lead more like CEOs than pastors, prophets or priests.

What would the education of the new professional look like? How might we prepare students at every level of education to be teachers, lawyers, physicians and clergy—to say nothing of parents, neighbors and citizens—who can challenge and help transform the institutions that hold such sway over our lives? How can education help professionals keep their hearts alive in settings where people too often lose heart? What might help them stand up to and sometimes against the institutions from which their paychecks, and perhaps their identities, come?

I have five immodest proposals regarding the education of a new professional: 1. We must help students debunk the myth that institutions possess autonomous, even ultimate, power over our lives. 2. We must validate the importance of our students’ emotions as well as their intellect. 3. We must teach our students how to “mine” their emotions for knowledge. 4. We must teach them how to cultivate community for the sake of both knowing and doing. 5. We must teach—and model for—our students what it means to be on the journey toward an undivided life.

I want to examine these proposals one by one. 1. We must help our students uncover, examine and debunk the myth that institutions are external to us and constrain us, as if they possessed autonomous powers that render us helpless—an assumption that is largely unconscious and entirely untrue. We professionals, who by any standard are among the most powerful people on the planet, have a bad habit of telling victim stories to excuse our unprofessional behavior: “The devil (boss, rules, pressure) made me do it.” We do this not only because it gives us a cheap ethical out but also because we are conditioned to think this way. The hidden curriculum of our culture portrays institutions as powers apart from us, over which we have marginal control at best, powers that will harm us if we cross them. It is true that we may pay a price for calling institutions to account, finding ourselves marginalized, defamed, demoted or dismissed. But the biggest price we ever pay comes not from without but from within. It comes from violating our own integrity, from failing to live by our own deepest convictions and callings.

The extent to which institutions control our lives depends on our own inner calculus about what we value most. These institutions are neither external to us nor constraining, neither separate from us nor alien. In fact, institutions are us. The shadows that institutions cast over our ethical lives are external manifestations of our own inner shadows, individual and collective. If institutions are rigid, it is because we fear change. If institutions are competitive, it is because we value winning over all else. If institutions are heedless of human need, it is because something in us is heedless as well. If we are even partly responsible for creating institutional dynamics, we possess some degree of power to alter them.

The education of a new professional would help students understand and take responsibility for the myriad ways we cocreate and re-create institutional pathologies. Such an education would call us to identify and examine our own shadows. Only when we name and claim our own shadows and become accountable for the darkness that we create will we be able to evoke “the better angels of our nature,” inner sources of light that make both individuals and institutions more humane.

2. If we are to educate a new professional, we must take our students’ emotional intelligence as seriously as we take their cognitive intelligence. We unconsciously give institutions more power than they possess because of what we are taught by this culture’s hidden curriculum. But we consciously give emotions less respect than they deserve because of what we are taught by the explicit curriculum: “Don’t wear your heart on your sleeve” and “Play your cards close to your vest.” The message is simple: if you want to stay safe, hide your feelings from public view. Conventional education elevates this folk wisdom to the status of philosophical truth by demanding that we stifle subjectivity for the sake of objective knowledge. But philosophers tell us that there is no necessary conflict between human subjectivity and objective knowledge. In fact, knowledge emerges from a complex interplay of the inner and the outer. And common sense tells us that the history of positive social change has been made only by people who wear their hearts on their sleeves—witness Rosa Parks, Václav Havel, Dorothy Day and Nelson Mandela—people whose capacity to name, claim and aim their feelings not only shaped their actions but also attracted millions to their causes.

So the education of a new professional would overturn the academy’s insistence that students suppress their emotions in order to become technicians. It would help students honor and attend to their feelings, especially painful ones like anxiety, anger, guilt, grief and burnout. Students would learn to explore feelings about themselves, the work they do, the people with whom they work, the institutional settings in which they work and the world in which they live. They would learn that painful feelings are not signs of personal weakness or sources of shame, and are not irrelevant to the complex challenges of knowing, working and living. In the case of the organ donor who died, that first-year surgical resident told the review board that she felt “overwhelmed.” But instead of riding that feeling into action, she apparently allowed it to shut her up and shut her down.

Academics sometimes dismiss this sort of appeal to the emotions as “touchy-feely.” Apparently they imagine that disdain will settle the issue. But the fact that good pedagogy requires attention to emotions has been demonstrated time and again across half a century of educational research.

3. My third proposal is that we start taking seriously the intelligence in emotional intelligence. We must do more than affirm and harness the power of emotions to animate both learning and leadership. If students are to learn and lead well, we must help them develop the skill of mining their emotions for knowledge. For the most part, academic culture honors only two sources of knowledge: empirical observation and logical reasoning. But we do not live by science alone. To survive and thrive, we also rely on the knowledge embedded in our feelings. In fact, science itself begins in the hunches, intuitions and bodily knowledge that lie behind testable hypotheses. And people who do good work of any sort, however technical, understand that not everything they need to know can be found in data points and cognitive constructs.

Good teachers, lawyers, physicians and leaders bring at least as much art as science to their work—and art is rooted partly in the affective knowledge that eludes our instruments and our intellect. But the subtext of most higher education is that emotions are the enemy of objectivity and must be suppressed. As a result, educated people tend to compartmentalize their feelings, acknowledging them in private life, perhaps, but regarding them as dangerous to professional life. Professionals are supposed to be in charge at all times (or so says the myth), and we fear that feeling too deeply will cause us to lose control. So education gives us precious little experience, let alone competence, at extracting work-related information from our feelings. The medical resident who felt overwhelmed when left alone with 35 intensive-care patients probably took her feeling as a sign of personal failure, which leads to guilt, panic and paralysis.

That sort of feeling may be a sign of failure, of course. But in this case, it seems clear that the resident’s feeling carried at least as much information about the dysfunctions of her work setting as about her own limitations. “So what?” might be a reasonable response to that observation—until we realize that the capacity to translate private feelings into public issues, when warranted, has been an engine of every movement for social change.

The new professional needs to know how to name and claim feelings, neither denying nor being dominated by them; discern whether and how they reflect in reality; ask if they have consequences for action; and, if so, explore them for clues to strategies for social change. Of course, not all personal feelings yield knowledge about the world; some really are reflections of personal rather than social pathologies. Mining our emotions for truth requires as much discipline as mining the senses and the intellect—and at the heart of that discipline is the winnowing of information in community.

4. So my fourth proposal for educating the new professional is that we offer our students the knowledge, skills and sensibilities required to cultivate communities of discernment. As we mine our emotions for knowledge, we need the same discipline that we use to mine our observations and thoughts: communal sorting and sifting that helps us distinguish fool’s gold from the real thing. Whatever our data source is, the key question is always the same: How much of what I claim to know can be verified from viewpoints other than my own, and how much of it is my projection? A disciplined process of group reflection—whether the group is a team working on a long-term problem or two people assessing a crisis—helps us tell the difference between the emotions that illumine our environment and those that reveal our own shadows. Both kinds of knowledge are valuable, but they invite quite different responses.

Unfortunately, faced with the claim that feelings as well as facts must be addressed in the education of the new professional, many faculty will say, “I’m a biologist (or sociologist or philosopher), not a therapist. So don’t ask me to be one.” Fortunately, I am not making any such request. Therapy done by amateurs is usually an especially ugly form of psychological violence. But disciplined group inquiry led by a skilled teacher is one of the most reliable ways to extract information from data of all sorts, including emotional data. And the more experience we have with this kind of inquiry, the more likely we are to read our own feelings accurately when there is no time to summon a group, as was the case with that beleaguered medical resident.

5. This brings me to my fifth and final proposal for the education of the new professional: we must help our students understand what it means to live and work with the question of an undivided life always before them. This means, of course, that our own lives and work as mentors must reveal what it looks like to be living that question. I do not mean that we must achieve an undivided life before we can teach about it; if that were the case, few of us would qualify, and those few would not include me. And yet as an imperfect person in an imperfect world, I can reveal to my students what it means to wrap my life around this question: How do I stay close to the passions and commitments that took me into this work, challenging myself and my colleagues and the institution I work in to keep faith with this profession’s deepest values?

Living that question can mean fulfillment or frustration or betrayal—by others or by oneself. Over time, it usually means all of that and more. Our students need to see how we, their elders, deal with the vagaries of fate while refusing to sell out either our professions or our own identity and integrity. And they need to see how, when we fail and fall down, as everyone does, we manage to get up again. Modeling what it means to live as a new professional also demands that we create academic programs that are open to student critique, challenge and change.

We may offer a curriculum that claims to prepare students to be change agents in some other place, at some other time. But if the hidden curriculum of the program says “Don’t mess with us!” the lesson our students learn is to stay safe by keeping quiet, which replicates the very problem that the new professional needs to help solve. When students go year after year as passive recipients of education, small wonder that they carry their passivity into the workplace. What they have learned at school is that keeping one’s mouth shut is a way to stay safe. But they have not learned—because we have not taught them—that opening one’s mouth to challenge what is wrong is a way to stay sane.

No, I am not thinking about an annual, scheduled student uprising! I am thinking about an academic culture that consistently invites students to speak out about the program itself, rewards rather than penalizes them for doing so, and encourages faculty and administrators to be responsive to student concerns. An educational program that emerges from a continuing collaboration of administrators, faculty and students is much more likely to produce new professionals than one that leaves students disempowered.

Trace the word professional back to its origins and you will find that it refers to someone who makes a “profession of faith” in the midst of a disheartening world. Sadly, the meaning of the word became diminished as the centuries rolled by, and today its root meaning has all but disappeared. By professional we now mean someone who possesses specialized knowledge and has mastered certain techniques in matters too esoteric for the laity to understand and has received an education proudly proclaimed to be “value-free.” The notion of the “new professional” revives the ancient meaning of the word. The new professional is a person who can say, “In the midst of the powerful force field of institutional life, where so much might compromise my core values, I have found firm ground on which to stand—the ground of my own identity and integrity, of my own soul—ground from which I can call myself, my colleagues and my workplace back to our true mission."

This article is excerpted from the afterword to the tenth-anniversary edition of Palmer's book The Courage to Teach. Reprinted by permission from Jossey-Bass, a Wiley imprint. Copyright © 1998, 2007 by John Wiley & Sons, Inc.