Sacrifice as a Part of Medical Education: A Reflection on the COVID-19 Pandemic

Abstract

The COVID-19 pandemic demanded significant sacrifices from medical learners. We examine the meaning of sacrifice and frame it as a “side effect” of being dedicated to the good of the patient. We contend that sacrifice has played a central role in medicine, even before the pandemic, for professionals and learners alike. We identify three limits to the role of sacrifice in medical education and practice to separate healthy from harmful experiences of sacrifice. Developing an understanding of sacrifice in medical education and practice can help trainees and clinicians know when to marshal resilient responses to healthy sacrifices and reject harmful sacrifices encountered. Maintaining this balance requires a broader reflection on the nature of medical schools and their ability to support virtuous professional identity formation.

The COVID-19 Pandemic is a Reminder of the Sacrifices Medical Professionals Make

The COVID-19 pandemic created unprecedented working conditions for many medical professionals, asking for significant sacrifices from many medical learners. From the early days of the pandemic, COVID-19 created challenges for all levels of medical learners.^1–4 Each group—from medical students to fellows—experienced different sacrifices. Medical students were asked to postpone educational opportunities for the safety of patients and themselves. Residents were asked to work longer hours and cover shifts for those who were ill or at higher risk of serious consequences from the illness. Fellows were asked to return to resident-level responsibilities that they had “graduated from” years prior. Despite these challenges, educators and learners creatively adapted their learning experiences.^5–7

In addition to educational sacrifices, many learners made personal sacrifices—such as adjusting the duration of their educational path, having less time at home, being unable to travel to visit loved ones, socially isolating, and changing family planning decisions. Some learners, including the authors, grappled with how to make sense of the sacrifices being asked of their profession as a whole during the pandemic. ⁸ Some were courageously quick in meeting the extraordinary human needs of the pandemic while others were thoughtfully cautious about being caught ill-equipped on the front lines. ⁹

Simons and Vaughan have written about clinicians’ and trainees’ sacrifices during COVID-19. ¹⁰ Going beyond these experiences with sacrifice during the COVID-19 pandemic, we reflect on the role of sacrifice in medical practice and how it can be conceptualized through a virtue ethics approach. A virtue ethics framework focuses on the development and application of character traits and has also been used to analyze challenges in medical education.^11–13 Virtue ethics is inherently an embodied framework. Virtues are characteristics of an agent—whether it is a person or an institution. A virtue approach has an advantage over other approaches when discussing practical topics like sacrifice in that it focuses the ethical analysis on individuals and their character development. Other frameworks focus on measuring and weighing consequences (consequentialism) or establishing and following moral rules (deontology)—either of which could be executed by artificial intelligence just as easily as (and perhaps better than) humans could. This person-focus is critical to avoid relegating healthcare professionals to just “service providers” or “prescribers” in the healthcare industry machine. Finally, we identify limits to sacrifice as a part of medical education and clinical practice and suggest how a virtue ethics framework could guide medical schools.

Sacrifice as a Part of Medical Practice Beyond COVID-19

Sacrifice is defined by the Oxford English Dictionary (OED) as “the surrender of something valued or desired for the sake of something having, or regarded as having, a higher or a more pressing claim.” ¹⁴

Framed this way, sacrifice is a core part of medicine. The practice of medicine requires both the surrender of something valued and a higher claim. Even before COVID-19, training required dedicating long hours to study, giving up personal hobbies, missing recreational activities, spending less time with loved ones, not being able to freely engage in entertainment, losing sleep, significant financial investment, delayed income, and disciplining one's mind and body. Patient care often occurs in a stressful environment and can involve physically taxing, and even dangerous, work. All of these involve surrendering freedom, money, rest, relationships, and pleasure.

What is the higher claim for which we surrender things we value? One could answer in multiple ways: stable work, a high-paying job, the social prestige of being a clinician, or following tradition by entering the family occupation. While these claims might be true for different people, we argue that a core, shared “higher claim” should be the good of our patients. Being a health professional means that we are oriented toward the good of the patient before us. ¹⁵ Fundamentally, the clinical encounter involves seeking the good of another—not of oneself. In a virtue ethics approach, the tendency to sacrifice for the good of others would be described as altruism, which the OED defines as “selfless concern for the well-being of others.” ¹⁴

Sacrifice in Medical Education

A virtue ethics approach to integrating sacrifice could be part of a broader movement to promote moral formation in medical education. ¹⁶ Every patient wants professionals who are honest enough to admit their mistakes, kind enough to be compassionate, humble enough to know when they are beyond their area of expertise, brave enough to care for the most complex illnesses, and loving enough to be at their side when they experience loss. The development into a professional who is willing to sacrifice for their patients—not out of compulsion but because they are oriented toward the good of their patients, is a laudable aim for medical learners. Yet, character formation as a part of formal medical training is unlikely to occur. Character development is difficult to effect and assess in formal curricula, even if educators widely support it as an educational goal. Instead, educators might consider looking to the informal curriculum where developing a willingness to sacrifice for patients could be viewed as a part of professional identity formation (PIF). PIF is the process by which learners come to “think, act, and feel like a physician.” ¹⁷ Discussing sacrifice as part of mentor-mentee relationships and in a vulnerable learning environment can help learners identify how their teachers and mentors have sacrificed. These strategies are part of the informal curriculum and are better suited for character development. ¹²

The pedagogical triangle (Figure 1)—a useful conceptual framework in education—can be used to anchor a discussion of how this might look. ¹⁸ First and foremost, teachers ought to continue their own PIF by engaging with the practice of medicine (a). This will create daily opportunities to orient themselves around the good of the patient, sometimes resulting in personal sacrifices. This engagement with the practice of medicine and identity formation will serve as an example for the students that they are mentoring and teaching (b). ¹² In turn, students will have mentors to follow as they engage with the practice of medicine and build their own professional identity (c). We also note moral learning does not only flow counterclockwise. In our experience, we have often learned from how trainees morally engage with their patients and the practice of medicine, which in turn influenced our own identity formation. This bi-directional, practice-based learning is located in the informal and hidden curricula and represents a necessary part of the role of character and identity formation in medical education.

Figure 1.

An adapted pedagogical triangle.

The Limits of Sacrifice in Medical Education and Practice

Learners should also be aware of the limits of sacrifice. First, sacrifice should be balanced against other ethical considerations. In a virtue ethics approach, sacrifice would have to be balanced with other virtues such as practical wisdom, justice, and integrity. For example, practical wisdom can guide when a sacrifice is costing the practitioner too much without providing commensurate good to the patient.

Second, certain emotional tolls in the practice of medicine should not be a part of a learner's experiences but are unfortunately hard to eliminate. Most, if not all of us, have been sworn at, yelled at, demeaned, discriminated against, or threatened in the workplace by patients or colleagues. For patients whose illnesses have limited their ability to control their behavior, this is not intentional, but we will always work toward a world in which volitional harassment no longer occurs. Nevertheless, many learners bravely continue to fulfill their duties to care for patients despite these barriers. We have a collective responsibility to gather the courage to set boundaries and to protect our colleagues by stepping when patients or colleagues are mistreating others.

Third, sacrifice should not become a goal of medical education or practice. We want to be clear that we are against the “no pain, no gain” mentality in training. Providing care, PIF, and the development of clinical excellence are the goals of medical education. Some sacrifices will be encountered along the way. To approach it masochistically from the other direction, with sacrifice and pain as a goal, would be a mistake. We disavow the “You cannot be a real doctor unless you suffer through…” mindset. We see sacrifice as a “side effect” of the orientation toward the patient good, but not as a gatekeeper to becoming a healthcare professional. We also denounce calculated appeals to self-sacrifice that thinly guise exploitive institutional policies toward their clinician workforce. ¹⁹ Yet, this manipulation of sacrifice and transforming it into an ideal does not obviate the need for an understanding and acceptance of sacrifice.

A Framework to Navigate the Path Forward for Medical Schools

Many difficulties remain. What happens when the “higher good” is not easy to perceive, such as when multiple goods are at stake? Or when a trainee is too exhausted at the end of a shift to identify and emulate the virtuous care they normally would? Or when a professional is burned out and no longer able to represent the ideal practice of medicine to their trainees? Or worse, when a professional is intentionally disregarding the good of patients? How are professionals and trainees to know when sacrifice has become out of balance at their institution or in their training program?

Consider a brief application of virtue ethics to an example of sacrifice in medical education. A recent medical education commentary pointed out the competing interpretations of a medical student who faxes requests for patient records and coordinates with outside healthcare professionals who are part of a patient's care team. ²⁰ Some view these tasks as “scut work” and contributing to “problematic norms.” On the other hand, one trainee—who voluntarily engaged in said tasks—views these as beneficial to patient care and an important part of understanding healthcare systems.

Our virtue ethics approach yields a few principles to this example. First, it affirms that menial, time-consuming tasks that are uncomfortable or frustrating can be understood as a sacrifice that stems from a commitment to delivering excellent care for the good of a patient. Second, it would point out that hierarchical, coercive pressure for students to do this as part of their training does not develop virtue. The adage goes, “character is what you do when no one is watching.” Character is also what you do when no one is coercing you. Next, the equilateral pedagogical triangle encourages not just students—but also residents, fellows, and attendings—to orient themselves around the patient's good even when it calls for sacrifice. The rest of the team should be establishing norms in which any member could be engaging in those or other “servile” tasks that are intended to benefit the patient. Finally, the virtue of practical wisdom would also set boundaries on attempting to complete every medical record request. Some records are less likely to be useful than others and some are almost impossible to obtain—making the time spent on trying to acquire them disruptive to the ability to perform other team responsibilities.

Moving from the individual to the institutional level, we call on the organizations and professional communities in which we practice (the center of the pedagogical triangle, see Figure 1) to evaluate how their priorities, missions, regulations, decisions, and cultures support or undermine the development of virtue through PIF and engagement with the practice of medicine (the sides of the triangle). Scholars have written extensively about the application of virtue ethics frameworks to institutions, and we think such a framework is useful to contextualize our arguments about sacrifice. Trying to appropriately manage sacrifice in the practice of medicine without a broader conceptual framework implemented by a nourishing institutional culture and a supportive community of practice is like trying to become a chess grandmaster without learning opening and endgame theory, studying the games of prior masters, being supported by a chess association, or regularly playing with others.

A full exposition of an institutional virtue framework for institutions is beyond the scope of this essay. In brief, key tenants of such an approach emphasize careful evaluation of the purpose of the institution, the institution's balance between forms of success and excellence, the institution's sustenance of the practices it is dedicated to, and the virtues of the individuals and the community that comprise the institution. ²¹ This framework has been applied to hospital environments, ²² and could be adapted to medical education. Related frameworks for character education in schools and universities have been developed to guide institutional leaders.^23,24

Medical schools that want to promote virtuous PIF could embark on an analysis to identify the purpose of the school, evaluate whether it is a morally worthy purpose, and use that as a lens for evaluating the programs and policies of the school. Leadership could carefully reflect on how they prioritize certain metrics of success (eg, profit, prestige, fame) over excellence (eg, training proficient, virtuous clinicians) and how the school's budget and curriculum operationalize those priorities. A medical school might ask whether the practices it houses (medicine, teaching, learning, and research) are flourishing. Finally, they might consider whether its policies and regulations support the PIF of its teachers and trainees. Do they promote a culture of dedication to the good of the patient, excellence in care, integrity, a commitment to justice, and the appropriate acceptance of sacrifice?

These questions can be asked much more quickly than they can be answered. An honest assessment of a medical school's support for virtuous PIF starts with a careful analysis of these aspects of the institution.

Conclusion

Sacrifice is often experienced by medical learners. While not all of it is justified, some of it is unavoidable when orienting oneself toward the goal of seeking the good of the patient. The role of sacrifice in the healthcare professions was catapulted into social consciousness with the “healthcare heroes” rhetoric during the COVID-19 pandemic. Yet, if we look carefully enough, sacrifice has been a common part of the learning process throughout the history of the practice of medicine. Acknowledging and discussing this presence helps the medical education community navigate the role of sacrifice in our learners’ experience, separating healthy from harmful understandings of this pervasive element of clinical practice. Sacrifice cannot be handled appropriately outside of the broader context of institutions and communities dedicated to supporting a virtuous practice of medicine.