It was spring of 2020, and I was in full personal protective equipment at the bedside of an elderly woman with COVID-19 pneumonia. I was trying facilitate a FaceTime call with her family when she started drifting out of consciousness.
“Doctor, please, we need your guidance,” said her daughter. “We know she is old and in poor health, but if we put her on life support would she pull through—or would we just be prolonging her suffering?”
“It is such a new disease, I honestly don’t know,” I replied. “I am so sorry.”
COVID has deeply humbled everyone, particularly those of us caring for people stricken with it. At the beginning of the pandemic, we had no proven treatments and no experience with how patients would do.
That was hard for me, and for a lot of other doctors. For many years, I prided myself in knowing the answer, whatever the question. Many times, I would leave a patient’s room after playing “the doctor with all the answers” in a case so complicated that knowing all the answers was just not possible, and an uncomfortable feeling would creep upon me. In retrospect, this false confidence was driven by pride—or maybe it’s better called insecurity. I told myself that it was what my patients wanted: the mask of authority, confidence, certainty.
While it was hard to say “I don’t know” to Ms. R.’s family, it was liberating, too, like a cognitive switch had been flipped. “Let’s talk about the way she has lived her life and what thoughts she shared with you about the end of life,” I said to them. “Then we can figure out how to proceed together.”
COVID-19 gave me a crash course in intellectual humility—and I think we’d all benefit from a humbler approach to patient care.
Why can’t doctors be more humble?
Like many other prosocial cognitive constructs, humility is central to most religious practices. It is one the Three Jewels (or basic virtues) of Taoism. In the Christian faith, humility before God and before all people is a key tenant. The word Islam literally means “submission” in Arabic.
The story of humility in medicine is slightly different. William Osler, one of the fathers of modern medicine, saw humility as a foundation for the practice of medicine—after all, the body is too complicated to fully understand, especially when it starts to fail. And, ultimately, we all die, no matter how much doctoring we get. As technology improved and relationships between patients and doctors changed, so did the field’s relationship to humility. During my training, I don’t remember the word ever being used.
Still, it should not have taken 20 years for an open-minded guy like me to grasp the importance of humility. Several factors conspire to make humility difficult to incorporate into medical practice.
While, in theory, humility is foundational in medicine, it is antithetical to the hidden culture of stoicism in medicine, where the vulnerability required of humility can be seen as weakness. Beyond simply weakness, humility may suggest incompetence. In a field where knowledge is the coin of the realm, quickly and confidently coming up with answers is largely how we see ourselves as being judged.
Humility is not only cognitively challenging, but it also requires time. In practice, humility requires asking more questions of patients and colleagues. That’s already hard in the era of assembly-line medicine, but it’s made much so worse in pandemic conditions, when surges in cases can make speed and triage essential. Indeed, researchers believe there is an evolutionary bias toward overconfidence, because confidence keeps us from getting bogged down in the hundreds of decisions we must make every day. Not that doctors won’t spend the time if needed—but in today’s environment, that can feel quite costly.
When humility is good for patients
How can the research on humility help us understand its role in health care? While not all researchers conceptualize it this way, I like the framework of two types of humility: intellectual and interpersonal. Both are important in delivering excellent health care.
Mark Leary at Duke defines intellectual humility as recognizing that a particular personal belief may be fallible, accompanied by an appropriate attentiveness to limitations in the evidentiary basis of that belief and to one’s own limitations in obtaining and evaluating relevant information. That seems like exactly how we would want to approach the diagnosis of a patient. We need to recognize that our baseline beliefs about a diagnosis may not be correct, as they might be based on weak or limited data. We need to be cognizant of the quality of all new diagnostic evidence and our biases as it comes in. Not surprisingly, there is strong evidence to suggest that intellectual humility guards against two well-known forms of bias in health care: anchoring bias (which leads us to rely too much on the first information we get) and confirmation bias (the tendency to find and favor information that supports our prior beliefs).
But does humility lead to more accurate answers? Yes, data so far strongly support the notion that intellectual humility leads to better decision making. While there has been no research proving humility leads directly to better outcomes in health care settings, doctors who ask for more consultations (who are willing to admit they might not know something and ask a colleague for help) will do better on standardized exams. This suggests intellectual humility ultimately leads to greater medical knowledge.
The benefits of humility for patients might go beyond simple decision making. This is where the idea of interpersonal humility comes in. That entails an appropriate view of our own limitations, combined with curiosity and a sense of value of the ideas and needs of others. This curiosity lends itself to a restraint of ego, modesty, and respectfulness. People with high measured humility are deemed more empathic, as well. Not surprisingly, research suggests we all like and trust humble people. Humility can lead to better relationships, according to one 2017 study, which leads to more trust—and other studies suggest that increased patient trust will improve health outcomes.
There’s another way humility can improve health care: by breaking down social hierarchies. In one study, the simple act of the doctors breaking custom and eating with the rest of the surgical team led to better outcomes for patients. Humility builds connection in the team; people feel freer to speak up, which can help prevent errors. Airlines have been working to break down social hierarchies for years for just this reason; as a result, it’s now all first names between pilots and crew.
Burnout is a huge problem in health care. Might cultivating humility be a way to foster well-being? Many researchers believe so, but as Mark Leary says, “This hypothesis is based mostly on an extrapolation from research.” Yet given the degree to which humility tracks with other well-being promoting behaviors, I plan teach the value of humility in my role as well-being director.
How we might cultivate humility in medicine
Can we learn to be humbler, and how do we engender this quality in our doctors? We all have a personality-driven set point for humility, but could culture and training raise our degree of humility? Can we make this happen?
Slowly, it is happening. One way is through training in cultural humility that is taking place at institutions around the world to address health disparities, particularly those that exist along racial lines. An earlier effort to address disparities promoted the idea of cultural competency, but this implies mastery over a body of knowledge, which is not possible when caring for a diverse, ever-changing population.
In contrast, cultural humility is a more dynamic, lifelong process of self-reflection, curiosity, and acknowledging one’s own and institutional biases. Its proponents hope that a workforce trained in cultural humility will have less implicit bias and better partnership with patients. Which sounds a lot like what researchers found with interpersonal humility in general, doesn’t it?
Stories are another way to open the door to humility—and as health care providers, we have a front-row seat to the unfolding of amazing stories every day. As I tell my students and colleagues, “Be curious, listen to your patients’ stories, and the beauty in humanities’ struggles and the mystery of the human condition will move and humble you.” Awe is potent enhancer of humility, as the Greater Good Science Center’s Dacher Keltner’s work demonstrates. For health care providers, getting drawn into our patients’ stories at the bedside starts a virtuous cycle: compassion, humility, awe, and a sense of meaning can all come together and give us the energy we need to thrive in these trying times.
Since that day with Ms. R. and her family, I have continued to be more open about my uncertainties. As a result, it has become easier to be my authentic self, to listen to others, and to more thoughtfully consider their views. I can join a patient’s care team rather than blithely captain it. The more I have done this, the more comfortable I have become; I have now come to feel in my body and see in the faces of my patients that humility is a good thing. Today, I feel like a different doctor walking into my patient’s hospital room—and that’s better for both of us.