A Reflection on Humility

What is the first task of one who pursues philosophy? To throw away self-conceit. For it is impossible for a man to begin to learn that which he thinks he already knows.

- Epictetus, Discourses, Book II ch. 17

            The field of medicine has never been famous for its humility. Accusations of the arrogance and overconfidence of physicians reappear again and again in our history. The currently declining trust in—and trustworthiness of—the medical establishment is a cause for concern well known to readers of this Substack. The perceived arrogance of our field has played a significant role in this decline and, leaving aside arguments over how justified the decline is, appearances matter[1].

We can distinguish between declining trust in physicians as opposed to large governmental organizations or the “medical establishment” as a whole. Physicians have fared better, I suspect, in part because much of the public anger is directed toward the bureaucratic behemoth, and in part for the same reason people tend to think Congress is terrible but think their own congressman is doing a fine job.  While the causes for the decline may not be identical in each case, they are surely interrelated, and physicians have a job to do in rebuilding that trust.  

A patient I see in therapy, following a recent string of frustrating and dissatisfying appointments with various specialists, asked me, “How is it that doctors can act with such arrogance when so many of them clearly don’t know what they’re talking about? I don’t think I’ve ever heard a doctor tell me ‘I don’t know’. Your profession has a serious problem with unearned confidence.” She is right, of course. We are not asked often enough to justify our reasoning and decisions, whether advising a patient in clinic or speaking to the nation on pandemic response. Many react defensively when asked to do so, giving the lie to the idea that we really understand what we’re talking about, instead of the more prosaic reality that we are often recommending something not because we truly know how, or even that, it works, but because it seems probable, jives with our intuitions, “that’s what the guidelines say”, or some other such justification. 

Epictetus—a Greek Stoic philosopher living almost two thousand years ago—has some good advice for physicians in the twenty-first century. He stressed to his students the central importance of humility in the process of learning—going so far as to berate them, often harshly, for their claims to knowledge that they did not possess. The task of philosophy was, for Epictetus, fundamentally about living well and fully realizing our humanity as rational creatures. Epictetus understood what was at stake: for the arrogant student does not simply fail to learn philosophy, he fails to develop himself as a person, condemning himself to a life of ignorance and unhappiness. 

Epictetus’ timeless admonishment that humility must precede any learning is not limited to philosophy, of course. Admitting one’s ignorance is the first step in acquiring any kind of knowledge, and medical knowledge is no exception. While some learners are naturally humble, it is helpful for those of little faith like me to see a demonstration of the truth or efficacy of their teacher’s claims before trusting them fully. But not all kinds of knowledge and expertise are demonstrable to the same extent, in the same ways, and with the same precision. In some areas of medicine, it is easy: the surgeon who has performed thousands of appendectomies with well-documented good outcomes can justly be credited with genuinely useful medical knowledge and skill. But in many areas of medicine, it is not so easy to assess who in fact has useful knowledge. This becomes truer to the extent that the physician’s action is temporally or causally distant from the outcome in question.

I remember irritating many of my attendings as a medical student with constant prodding to justify their decisions and claims. Many were answered to my satisfaction, but many others bottomed out at “trust me because I have experience”. For the skeptical-minded learner like me, this didn’t quite cut it. Once an attending asked me why I was so persistent in my questioning, and I explained that often I had no good way of knowing who really knew what they were talking about and was worth listening to. We often don’t have clear objective metrics on which to base judgments of medical competence. If we were talking about chess or Brazilian Jiu-Jitsu instead of medicine, I told him, and he were Magnus Carlson or Rickson Gracie, we wouldn’t be having this conversation. His mastery would be evident not just from objective metrics of past performance, but by his ability to checkmate or submit me a hundred out of a hundred times.

Despite our technological advances in diagnosis and therapeutics, I’m not convinced we have made similar advances in our ability to say, “I don’t know” and “I was wrong”. Luckily, crises of confidence—whether personal or societal—can have the salutary effect of spurring one toward introspection and reflection. We can pause and take stock of what we think we know and, if we’re lucky, find our errors and gracefully correct them. I don’t know how much introspecting the CDC or FDA are doing, but luckily there is nothing stopping us from doing it ourselves.

For my part, I try to remember that a physician is little more than a temporary custodian, stewarding patients toward health with the relatively crude tools at our disposal. I recall that the great majority of factors affecting the outcome are beyond my control, and that I can no more influence them than a sailor can command the wind. I recall that I am only one thread in the vast causal chain of someone’s life and that their improved health may owe less to my own intelligence than I would like to think. The spirit of humility is captured in the words of Ambroise Paré, the 16th century French surgeon, who once remarked of a patient “Je le pansai, Dieu le guérit”—I bandaged him, God healed him[2].

How proud should we be of our accumulating degrees and credentials, which seem to be growing at a rate far outpacing the growth of our knowledge? In our focus on evidence, data, studies, and expertise, are patience, wisdom, and humility being forgotten? Might we be better off saying “I don’t know” and “I was wrong” more often? How much of what I think I know is merely the reflection of a comfortable consensus, some “standard of care”? Do I, perchance, ever engage in motivated reasoning? If I take time to examine how much I know—I mean really know—about medicine, I inevitably find my pretensions falling quite short. 

Cultivating humility is difficult. I should know—I’ve been failing at it for more than thirty years. I suspect that what little progress I have made comes during those moments when I become aware that I need to slow down. Easier said than done if you’re a busy doctor, but then again who would be comforted knowing their doctor is doing a rushed job? As Rabbi Simcha Zissel Ziv says, “Take time, be exact, unclutter the mind.” In this respect, I understand the virtues of humility and patience as being intimately related[3]. In slowing down, you can more easily restrain your domineering ego. You can focus on the people and things close to you and tune out the noise. You can take time to arrive at the truth or marshal up the courage to say you’re confused and need help. You can admit you were wrong and make amends. And you will be happier.

It is an absolute perfection and virtually divine to know how to enjoy our being rightfully.  We seek other conditions because we do not understand the use of our own, and go outside of ourselves because we do not know what it is like inside.  Yet there is no use in our mounting on stilts, for on stilts we must still walk on our own legs.  And on the loftiest throne in the world we are still sitting only on our own rump.

- Michel de Montaigne, Essais, Book III ch. 13, Of Experience

Martin Greenwald, M.D.

Dr. Greenwald is a psychiatrist practicing in the midwestern United States.

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[1] “It is only shallow people who do not judge by appearances.” - Oscar Wilde

[2] There are many similar varieties, including the latin “medicus curat, natura sanat”—the doctor cares [for the patient], nature heals.

[3]  Perhaps this is just a reflection of my lacking in both.