By David C. Leach

William Butler Yeats said: “We make out of the quarrel with others, rhetoric, but of the quarrel with ourselves poetry.” During the course of normal human development most people at some point have had their hearts broken, cherished beliefs challenged, paradoxes entertained or have been lonely or felt abandoned. Sometimes these moments can offer powerful prompts to turn inward and to enhance one’s reflective capacities, one’s poetic repertoire, and this in turn can enable learners and faculty to be more compassionate and reflective practitioners. The alternative responses, hardening the heart, embracing idols, not honoring the paradox or becoming ever more isolated can have devastating effects on both the learner and their patients. Moving from rhetoric to poetry is an important skill for learners to develop…

The first skill, how to break your heart, is in many ways the toughest and also the most important. Healthcare is full of heartbreaking experiences for patients, their families, and for healthcare providers. Heartbreak in one’s personal life can prepare the learner for these experiences and make them more effective practitioners. Parker Palmer describes two approaches one helpful and one not. A frequent defensive response involves hardening the heart and becoming cynical. Unfortunately when a hardened heart shatters sharp and damaging chards can injure innocent bystanders. A better approach is to soften and expand the heart to accommodate the difficult reality confronted at the time.  Enlarging the heart frequently involves forgiving others and oneself; it enables the heart to “go out” to others.  It is hard but essential to learn to forgive, or to borrow the title of Charles Bosk’s famous book to forgive and remember.

Humans are designed to seek out the truth. Truth seeking involves both learning and unlearning. The lazy truth seeker lacks the skill of unlearning and settles prematurely on a lesser truth, becoming very attached to a view of the world that comforts them but is inaccurate. In a sense they worship their own mental construct at the expense of exploring the deeper truths found in reality. It’s a form of idol worship. In the clinical arena this may translate into a dogmatic diagnostician who ignores any emerging data that does not fit their hypothesis. Learners should have a bias toward reality and the humility to be open to the truth. They can learn this from their personal life and apply it directly to their work.

It is said that one mark of intelligence is the ability to be comfortable holding two incompatible ideas in one’s head at the same time. The temptation, of course, is to pick one arm of the paradox or the other and forgo the opportunity for deeper reflection. For example, the recent rhetoric around gun control invites one to pick one side or the other. Yet once internalized the paradox may be expressed as a commitment to both nonviolence and to protection of self and others. Holding the tension of both arms of this paradox can result in a deeper understanding of what love of neighbor really means.

Recently graduated nurses may have supervision for as little as six weeks and then be left alone to care for very sick patients. Resident physicians, in spite of regulations to the contrary, are sometimes inadequately supervised and, in a sense, abandoned. These searing experiences offer painful but effective occasions for reflection, reflection that can lead to humility, truthtelling, and the establishment of a more effective and reflective community of practitioners. It is a form of crucible learning. The alternative of false bravado and embellishment of skills is extremely destructive for both learners and their patients.

Being mindful of and identifying occasions of heartbreak, mental idols, paradoxes, or abandonment can enable learners and practitioners to use these substrates to enhance their reflective capacities and to become better clinicians. Even painful experiences can bear fruit.

David C. Leach, MD, was trained and practiced as an endocrinologist.  He served as the Executive Director of the Accreditation Council for Graduate Medical Education (ACGME) from 1997 – 2007. He is a member of the Board of Trustees of Mercy Health.