ten generalist virtues (and how to cultivate them)
According to the Michigan State University College of Human Medicine (MSU/ CHM), the three key virtues of the ‘virtuous professional’ are courage, humility and mercy. Courage includes the readiness and ability to do what is ethically best. Humility ‘refers to a deep appreciation of the limits of our knowledge, skills or abilities to make the right decision’. Finally, mercy ‘refers to our disposition to meet the needs of others out of empathy’. These three virtues, which are also described as ‘ideals’, are said to support ‘the highest exercise of our professional responsibilities’. MSU/CHM lists six professional responsibilities: competence, honesty, compassion, respect for others, professional responsibility and social responsibility:
Although there is undoubtedly an element of arbitrariness in the division of virtues and responsibilities, nobody could argue with the suggestion that courage, humility and mercy are generalist virtues. What is less obvious is that they are specifically generalist virtues. Rather, they are virtues that all professionals and perhaps all human beings should have. They are not tied to, or preconditions of, the medical generalism per se. The virtues of medical generalism per se are those personal qualities that enable medical generalists to fulfil their professional role, achieve the goals of medical generalism and meet its professional challenges. Having already identified these roles, goals and challenges, as well as medical generalism’s orientation, ways of working and distinctive modes of knowledge, (see Defining Medical Generalism), it should now be possible to list its enabling virtues.
The status of attentiveness as a generalist virtue is a reflection of generalism’s orientation and the biographical understanding it seeks. Medical generalism’s whole person orientation means that it must be serious about engaging with the individuality and subjectivity of patients, as well as the context of their family and social environment. Engaging with these things requires a high degree of attentiveness on the part of the generalist, a willingness to attend to individual narratives and the subjective reality of each patient. Engaging with each patient as an individual in his or her own right makes considerable emotional and intellectual demands on the medical generalist, and one thing it demands is the generalist’s undivided attention.
The indispensability of the virtue of attentiveness is also implied by the core generalist value of respect for persons. As Iona Heath puts it, ‘if healthcare systems are to treat people as ends in themselves and thereby recover the self and respect the subjectivity of both patients and professionals, the primary requirement is that we should pay genuine attention to each other’ (p. 85). If this is right then attentiveness is a moral as well as practical requirement on the medical generalist.
Another implication of the distinctive orientation of medical generalism is that it requires the generalist to have the virtue of curiosity. As the philosopher Neil Manson has noted, curiosity can be a vice when it is excessive or inappropriately targeted. There are some things about other people, perhaps other than one’s nearest and dearest, that it is better not to know and better not to want to know. Respect for another person’s privacy requires at least a degree of incuriosity. Nevertheless, curiosity is a generalist virtue when it is not excessive and properly exercised. How is it possible to understand a patient’s fears, hopes, needs and values if one doesn’t know what they are? And how is it possible to come to know about these things unless one is curious enough to find out?
The status of curiosity as a generalist virtue flows in part from the role of biographical understanding in general practice. The conscientious medical generalist must seek least a degree of biographical understanding of his or her patients (see Defining Medical Generalism). The desire for such understanding is a form of curiosity. However, an effective generalists’ curiosity is not confined to their patients. There is also the need for a more abstract form of intellectual curiosity about biomedical science. There is the need to ‘keep up’ with the latest research, to the extent that it is relevant to general practice. An intellectually curious medical generalist is more likely to keep up than one who is incurious or disinterested.
Just as it is possible to be too curious about a patient, it is possible for a medical generalist to become too emotionally involved and too deeply affected by their pain or distress. Such excessive involvement or concern can impair one’s medical judgment and be destructive of the medical generalist’s own well-being. This is why the right degree of detachment – not too much or too little – is a genuine generalist virtue. Detachment is the golden mean between casual indifference and excessive involvement. It is closely related to objectivity.
The appropriate degree of detachment is compatible with genuine concern for one’s patients but does not impair one’s judgement or impose excessive emotional demands on the generalist. It is a form of emotional self-care that makes generalists more resilient and less prone to burn-out. In order to care for their patients, generalists must care for themselves. Anything that contributes to the generalist’s professional self-care has a reasonable claim to be regarded as a generalist virtue.
Empathy is often described as a generalist virtue and part of what the RCGP calls ‘the ethos of medical generalism’. On the other hand, empathy also has its critics. In his book Against Empathy, psychologist Paul Bloom distinguishes between empathy and compassion and argues that ‘when it comes to certain interpersonal relationships, such as between doctor and patient, compassion is better than empathy’ (pp. 50-51).
What is empathy? Writing in the 18th century, the philosopher and economist Adam Smith represented empathy – which he called ‘sympathy’ – as the means by which we are able to know what other people are feeling. Since we can’t experience other people’s feeling directly, we put themselves in their shoes and imagine what we would feel in the same situation. According to Smith, this is the ‘source of our fellow-felling for the misery of others’.
The empathy that Smith describes is sometimes referred to as emotional empathy. Emotional empathy, as the label suggests, engages the emotions of the empathizer and so isn’t a purely intellectual exercise. The contrast is with cognitive empathy. In cognitive empathy, one appreciates what another person is feeling but without mirroring their feelings. This is how Bloom describes the contrast: ‘if your suffering makes me suffer, if I feel what you feel’ (p. 17), that’s emotional empathy. If I understand that you are in pain without feeling it myself then this is cognitive empathy.
What kind of empathy is a virtue for the medical generalist? Some have argued that the whole person orientation of medical generalism means that the medical generalist must be willing and able to engage with the fears, hopes, needs and values of each individual patient. Engaging with another person’s emotions means understanding what they are, and that requires cognitive empathy. Without empathy, other human beings become unreadable. It is also sometimes suggested that the professional role of medical generalists includes ‘bearing witness’ to the suffering of their patients. How can one witness suffering without recognizing it, and how can one do that without some cognitive empathy?
Yet cognitive empathy is cold and bloodless. Merely understanding a patient’s pain or suffering is not that same as engaging with it. Doesn’t that require full-blooded emotional empathy? Isn’t it necessary to feel their pain and not merely understand it? How can one really understand it if one doesn’t feel it? This suggests that cognitive empathy isn’t enough; doctors also need emotional empathy. However, critics of emotional empathy say that it is biased. As Bloom writes, ‘it’s far easier to empathize with those who are close to us, those who are similar to us, and those we see as more attractive or vulnerable and less scary’ (p. 31). What we all need, Bloom argues, is not emotional empathy but compassion. It isn’t possible to empathize with the starving millions but it is possible to have compassion for them. Compassion is both more diffuse and less biased than empathy. In particular, it doesn’t require one to ‘mirror’ others people’s feelings.
There is also a more straightforward practical objection to classifying emotional empathy as a generalist virtue: it would be emotionally and psychologically disastrous to feel the pain or suffering of every patient. The generalist who tries to do that would burn out very quickly and, in all probability end, up as an emotional wreck. The same goes for other branches of medicine. Bloom quotes a surgeon saying that she would be incapacitated if, ‘while listening to the grieving mother’s raw and unbearable description of her son’s body in the morgue’ (p. 142), she was to imagine her own son in his place. What doctors need is not this type of empathy but compassion, or empathy understood as compassion.
Yet there is something right about the concern that fully understanding another person’s predicament requires some degree of emotional engagement with that person, even if it doesn’t require one to mirror their feelings. In the words of the philosopher Olivia Bailey:
‘A rough and ready way of thinking of about emotions’ role in empathy is to conceive of the empathizer as encountering the other’s situation through an appropriate emotional lens. When we try to empathetically imagine how things are for a recent widower, for instance, we attempt to look at his situation through the lens of grief’ (p. 144).
Looking through the recent widower’s situation ‘through an appropriate emotional lens’ doesn’t require one to be grief-stricken in anything like the way that the widower is grief-stricken. On the other hand, it isn’t mere compassion or cognitive empathy. Empathy in Bailey’s sense ‘is not bloodless or coldly cognitive’ (p. 144) and is, at least to this extent, a form of emotional empathy. It is this type of moderate emotional empathy that is required to really engage with and properly understand another person’s feelings. It follows that moderate emotional empathy, combined with compassion, is a generalist virtue.
There is an obvious problem with regarding both emotional empathy and detachment as generalist virtues. Detachment requires generalists to maintain an emotional distance from their patients that seems incompatible with emotional empathy. This tension is genuine and not easily resolved. The medical generalist must be willing and able to look at every patient’s situation through the appropriate emotional lens, while also maintaining enough emotional distance not to be emotionally incapacitated or lose their objectivity. This is the point of the idea that the empathy that is a generalist virtue is moderate emotional empathy. As with all virtues, it is possible to have too much or too little of a good thing and that applies to empathy as much as to anything else. Moderate empathy is compatible with a degree of detachment but isn’t bloodless or coldly cognitive. It still places considerable demands on the generalist, and that is why the practice of generalism also depends on another professional virtue: resilience (see below).
According to the philosopher Alessandra Tanesini, humility is ‘concerned with human limitations in general and one’s own limitations in particular’. It is not just a matter of recognising one’s limitations but of owning them, of taking them to heart. Intellectual humility is concerned with one’s intellectual limitations while epistemic humility focuses on limitations in one’s knowledge and ability to know. This is how the philosopher José Medina describes the benefits of humility:
‘Having a humble and self-questioning attitude toward one’s cognitive repertoire can lead to many cognitive achievements and advantages: qualifying one’s beliefs and making finer-grained discriminations; identify one’s cognitive gaps and what it would take to fill them; being able to formulate questions and doubts for oneself and others; and so on’ (p. 43).
Understood in this way, humility is a human virtue: it contributes in obvious ways to human flourishing and, in particular, to human intellectual flourishing. Is there any reason to regard humility specifically as a generalist virtue? Why do so many accounts of the medical virtues, such as the one put forward by the Michigan State University College of Human Medicine, take it for granted that humility is not just a human virtue but a professional virtue?
The rationale for highlighting the importance of humility in general practice is straightforward. It is one thing to insist that the task of the clinician is, as Iona Heath puts it, to ‘engage with the details of the fears, hopes, needs, and values of each individual patient’ (p. 84) but there are limits in the generalist’s ability to do this. It isn’t just that generalists have limited time and energy to get to know their patients but that knowing other people and their problems is inherently difficult. Medical generalists who seek a biographical understanding of their patients would be well advised to recognize that this type of understanding is not always possible. Patients, like human beings generally, vary enormously in how easy or difficult they are to read, and the recognition of this obvious fact by the medical generalist is a form of professional humility.
Another important form of professional humility pertains to the biomedical rather than biographical component of generalist medicine. It involves recognising the limitations of biomedical understanding and the inherent uncertainty of medical knowledge. General practice is not an exact science, especially in relation to patients with indistinct conditions, multiple morbidities and chronic illnesses. The limitations of medicine are well understood by most generalists and their understanding of these limitations is a form of professional humility. Professional humility matters because it keeps the expectations of doctors and patients in check and might also play a role in combatting overdiagnosis and what has been described as the ‘medicalization of human suffering’ (see Defining Medical Generalism, section 8).
It has been suggested by Peter Toon that many people go to their GPs not principally because they want to change what is happening to them but because they want to understand it (see Defining Medical Generalism, section 5). This is the interpretive function of generalist medicine: giving patients prognostic information and helping them to understand their illness.
In order to do this effectively, medical generalists need to be excellent communicators. In particular, they need to be lucid. Lucidity pertains to speech and to thought. A lucid speaker is one who speaks clearly, in a manner that is easy to follow but without any sacrifice in accuracy. A lucid thinker is one who thinks clearly. Being a lucid thinker makes it easier to be a lucid speaker, and both forms of lucidity are generalist virtues: medical generalists need to be lucid if they are to communicate effectively with their patients and help them to understand what is happening to them.
The indispensability of resilience has already come up in relation to empathy. The emotional demands of generalist medicine are difficult to exaggerate. Among the virtues of generalist medicine are those that contribute to generalist self-care. A way to reduce the emotional burdens of generalist medicine is to keep one’s emotional distance from one’s work and one’s patients. It is possible to cultivate the virtue of detachment as a way of coping with the stresses of generalist medicine but there are limits to how detached the generalist can be or should be. It is because the generalist cannot afford to be too detached and must be capable of at least moderate emotional empathy that resilience is required. The greater the openness to stressful emotions, the greater the need for resilience.
The American Psychological Association defines resilience as ‘the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress’ (https://www.apa.org/helpcenter/road-resilience). It is the ability to bounce back from difficult experience and recover one’s equilibrium. A resilient person is not unfeeling or indifferent. An unfeeling person has no need for resilience since their insensitivity is sufficient protection from distress. The need for resilience only arises if one is not indifferent, if one can genuinely relate to the suffering of others. To the extent that medical generalists need to be able to relate to the suffering of their patients they need to be resilient.
Self-trust is trust in one’s own knowledge, abilities and judgements. Self-trust is closely related to self-confidence. Without the appropriate degree of self-trust and self-confidence it is difficult for any professional to function effectively. Self-trust is even more important in medical decision-making. In order to diagnose one’s patients it is essential that one trusts oneself to make an accurate diagnosis. The alternative is intellectual paralysis.
Knowledge requires a degree of confidence. If one knows that something is the case – that a patient has a chest infection, for example – one must be reasonably confident that it is the case. To be reasonably confident one must trust oneself to know, and trusting oneself to know is a basic form of self-trust. It follows that lack of self-trust is a threat to one’s knowledge. There is more on the links between knowledge, self-confidence and self-trust in this TEDX lecture:
To say that one must trust oneself is to not say that one must trust oneself and have confidence in one’s judgement regardless of the evidence of one’s actual level competence. Self-trust needs to be earned and properly calibrated. It isn’t justified unless one is in fact a competent judge. The generalists’ degree of self-trust can and should vary according to career stage. It is appropriate that the self-trust of a newly qualified generalist is lower than that of an experienced colleague. Even in the case of the experienced medical generalist, self-trust needs to be combined with humility. It is a question of balance. The virtuous professional is neither lacking in self-trust nor excessively self-confident. Human fallibility, including one’s own fallibility, must never be ignored.
9. situational judgement
The philosopher Ludwig Wittgenstein noted that for any given set of rules or guidelines there is always the question how they apply in a given case. Guidelines do not interpret themselves and it is always a matter of judgement whether and how they apply to an individual patient. The application of a rule or guideline involves moving from the abstract to the concrete and it is judgement that mediates this transition. This is how Sally and George Hull make the point:
‘The skilled practice of generalist medicine may include knowing a set of abstracted rules and recommendations. But the work of a skilled GP could not be substituted by the mechanical application of a list of rules- however long. This is because it relies crucially on making situated judgements with the patient. Decisions are rooted in the immediacy of the patient context’ (p. 2).
As Wittgenstein also noted, this problem can’t be solved by positing rules for the interpretation of rules because the rules for interpretation would also need to be interpreted. If one is to avoid an infinite regress of rules it is necessary for practitioners in any field to rely on their judgement, their sense of how a rule or guideline applies in the case at hand. Trisha Greenhalgh adds that:
‘Situational judgement is particularly crucial in specialities characterised by a high degree of uncertainty, such as general practice. Time and again, evidence-based guideline proves ambiguous, incomplete, or throws light on a similar but not identical problem to the one that needs solving right now’.
The difference between an excellent and less than excellent generalist is often a difference in the quality of their situational judgement. Experience and practice can improve a generalist’s judgement, and excellent situational judgement is among the virtues that must be acquired and manifested by the excellent medical generalist.
10. testimonial justice
Testimony, in the philosophical sense, is the conveying of information by telling. If a patient tells a doctor that she has a sore elbow, and the doctor comes to know as a result that the patient has a sore elbow, then the doctor’s knowledge is what philosophers call testimonial knowledge. Testimony, in this sense, is not confined to the courtroom. It happens ‘whenever one person tells something to someone else’ (https://www.iep.utm.edu/ep-testi/).
There are cases in which, although the speaker is trying to share what she knows with someone else, she fails to do so because the hearer doesn’t regard the speaker as credible. In these cases, the conveying of information by telling is stymied. Prejudice is among the many factors that can lead a hearer to discount a speaker’s testimony. In such cases, the speaker is regarded as lacking in credibility on account of her race, gender, class, or some other aspect of her identity. Where the transmission of testimonial knowledge is stymied by the hearer’s prejudices the speaker is a victim of what philosopher Miranda Fricker calls ‘testimonial injustice’. Testimonial injustice occurs when prejudice causes a hearer to give a deflated level of credibility to a speaker’s word. In one kind of case, the hearer doesn’t take what the speaker says seriously because the speaker is a member of a marginalised social group.
In recent years, work by Havi Carel, Ian James Kidd and Sally and George Hull has explored the impact of testimonial injustice in healthcare. Kidd and Carel refer to complaints by patients that ‘healthcare professionals do not listen to their concerns, or that their reportage about their medical condition is ignored or marginalised, or that they encounter substantial difficulties in their efforts to make themselves understood to the persons charged with their diagnosis and treatment’. The reason, as Sally and George Hull note, is that:
‘Chronically sick people are a group liable to be regarded as less credible by society in general, particularly when they are also elderly and/ or poor. Doctors are not immune to pervasive social prejudice, and those same prejudices in the doctor’s mind and sensibility can very well lead them to discount or not take seriously the testimony of a patient in consultation’ (p. 11).
Kidd and Carel give many striking, and indeed shocking, examples of this form of testimonial injustice and its negative impacts on interactions between doctors and patients. Clearly, testimonial injustice potentially affects all branches of medicine. For example, it is at odds with the requirement that all doctors treat their patients with equal concern and respect, regardless of class, gender, race, sexual orientation, or health status. However, there are features of generalist medicine that make testimonial injustice especially problematic in that context. Generalism is a collaborative practice involving both patients and professionals, and it is difficult to see how it can be genuinely collaborative if the prejudices to which generalists are not immune lead them to regard some of their patients as lacking in credibility or as not to be taken seriously.
According to Fricker, ‘the virtuous hearer neutralizes the impact of prejudice in her credibility judgements’ (p. 92). The virtue that such a hearer possesses and exercises is the virtue of testimonial justice, the capacity to neutralize prejudice in one’s judgements of credibility. One way to exercise this virtue is to be prepared to think critically about the extent to which one’s judgements of credibility are prejudiced and to make suitable adjustments to counteract the influence of prejudice. The virtue of testimonial justice facilitates mutually respectful collaborations between doctor and patient and, in this way, helps medical generalists to fulfil a key element of their professional role.
According to Sally and George Hull, ‘GPs are generalists whose medical expertise consists, to a significant extent, in the possession of a set of virtues’ (p. 3). What if an aspiring generalist doesn’t already have all the necessary virtues? What can they do to acquire them? A virtue, the Hulls argue, is ‘an acquired disposition of character, so a good generalist medical training should develop settled dispositions of character in a GP which enable them to make the right judgements in consultation with their patients’ (p.3).
How realistic is this? Like Aristotle, the Hulls assume that virtues are character traits. Again like Aristotle, they assume that character traits, understood as dispositions, can be acquired by training. Some philosophers have argued that, while our characters are relatively malleable during childhood, they are extremely hard to change or revise one they are fully formed in adulthood. If this is right then is it not completely unrealistic to expect medical schools, or anyone else, to help generalists to acquire and develop character virtues they don’t already have? If character is destiny it follows that only individuals who already have the relevant traits are cut out for medical generalism.
There is an ongoing debate in philosophy and psychology about the malleability, or otherwise, of character traits. However, it is not necessary to think of virtues generally as character traits. Virtues like humility are not so much character traits as attitudes. A humble person has a particular attitude towards their own limitations. A curious person has a particular attitude towards discovery. Empathy is an attitude towards other people. Other virtues are more like skills than either attitudes or character traits in the ordinary sense. This is true of lucidity and situational judgement.
This matters because attitudes can be changed and skills can be acquired. People who are advised to change their attitudes aren’t being asked to do something that, in general, can’t be done. One’s attitude towards something is one’s posture towards that things, and postures can be changed. The various skills and attitudes listed above can be taught and learned. Self-improvement is possible, at least to some extent, and this should put paid to any idea that the generalist virtues can’t be cultivated.
Skills are acquired by training and practice. Attentiveness can be improved by practice and one’s situational judgement can be improved by training. Attitudes can’t be changed at will but can be changed indirectly by exposing oneself to a wider range of experiences and influences. In all cases, change is easier if one is motivated to change. I have written more about self-improvement elsewhere (see below).
references & further reading
Neil Manson’s work on curiosity is here: (https://philpapers.org/rec/MANERA).
All quotations from Iona Heath are from her paper ‘The subjectivity of patients and doctors’ in Christopher Dowrick (ed.) Person-centred Primary Care. Also in this volume is the paper by Sally and George Hull, ‘Recovering general practice from epistemic disadvantage’.
The fill title of Paul Bloom’s book is Against Empathy: The Case for Rational Compassion.
Olivia Bailey writes about empathy in this paper: https://philpapers.org/rec/BAIEAT
This is Alessandra Tanesini’s paper on humility: https://philpapers.org/rec/TANIHA-9
The José Medina quotation is from here: https://global.oup.com/academic/product/the-epistemology-of-resistance-9780199929047?cc=gb&lang=en&
This is the paper on ‘Epistemic Injustice and Illness’ by Ian James Kidd and Havi Carel: https://www.ncbi.nlm.nih.gov/pubmed/28303075
Fricker’s work on testimonial injustice can be found here: https://global.oup.com/academic/product/epistemic-injustice-9780199570522?cc=gb&lang=en&
The Trish Greenhalgh quotation is from: https://www.cebm.net/2016/01/5395-2/
My work on self-improvement can be found here: https://global.oup.com/academic/product/vices-of-the-mind-9780198826903?cc=gb&lang=en&