Stewardship
The principle that underpins effective medicine and better living.
Names were changed to protect patient information…
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After a weeklong marathon of enduring needles to receive blood, scopes to hunt down disease, and scalpels to remove the cancerous tumor growing deep in her belly, Anne lay in a hospital bed — anemic, exhausted, and exasperated. This was a woman who had cherished her health for over eighty years. Rarely seeing a doctor, for doctors were little more than pill-pushers in hospital pajamas, she emphasized a life of exercise, healthy eating, and strong family relationships. She took care of her disabled husband. She operated her own home garden. Harboring an intense suspicion of Big Pharma, she researched nutrition and self-prescribed a variety of supplements. In our initial meeting, she proudly boasted about how she cured her husband’s thyroid disease with selenium… and boasted rightly so. She was a person who cared deeply for her own health and the health of those close to her. There was no apathetic bone in her body or thought in her mind.
Now here was I, the ignorant pajama-clad pill-pusher, tasked with informing her that, in addition to her colorectal cancer, we discovered she had diabetes. She needed longterm medication.
Seated next to the bed, I spoke to her in the presence of her husband and eldest daughter. Some time along the way, maybe after fifteen minutes of discussion, it dawned on me that we made little, if any, headway. This news was simply unbelievable. She described again and again the extreme standard of health to which she held herself. Talking aloud, half to me and half to the world, seemingly an effort at bargaining, she shared her wellness regimen once again and exclaimed, “I just don’t understand how my sugars could be this high…”
To which I simply replied, “That’s diabetes. You have diabetes.”
Then we all sat together in silence.
Resources and Relationships
Stewardship is the principle of managing the resources entrusted to one’s care and doing so to an exceptional degree. A classic example of a resource one “stewards well” is land or property. The National Parks Service conserves natural land, protecting it from industrialization, human interference, and corruption.
In addition to the “material,” resources can be characterized as “immaterial.” For instance, if one manages their time effectively we say they are efficient and productive… a good steward of their time. Within the context of medicine and health, stewardship is an important principle due to the nature of the doctor-patient relationship. We can examine this by going down three different avenues, using our patient “Anne” as a guide:
Our relationship with ourselves - Anne saw herself worthy of the effort of healthy living. She had purpose — to care for her husband and family — and knew that the vehicle of that care must be maintained well.
Our relationships with things - Anne identified consequential relationships with things that would promote either well-being or decay. For instance: nutrition. She viewed food as fuel and even went so far as to garden her own vegetables. Additionally, Anne identified needless pharmaceuticals as something to avoid. This is true, as needless medications certainly cause more harm than good.
Our relationships with others - At the core of medicine — past, present, and future — is the relationship between doctor and patient. It is the physician’s role to foster trust, act in their patient’s best interest, and do no harm. A physician must steward the relationship with their patients, understand the tenets of both health and disease, stay up-to-date on medical innovation and treatment, develop their craft to a level of mastery, and communicate effectively with patients in need of their expertise. It is the patient’s role to care for themselves; to hold themselves to a high standard of health like Anne. Additionally, patients must make physicians prove themselves and, when the physician does, to be receptive to their counsel. In the case of Anne, I previously established trust by lending her my stethoscope as ears, being patient with her, understanding what was important to her, and speaking directly to that. I established my role first and foremost as someone who was of good character; someone who could be trusted. From this vantage point, as a trusted advisor, I gave strong recommendations based squarely on my character, our relationship, and my education.
Side note: Being a first-year resident, aka an “intern,” it’s unwise to try and give recommendations to patients based off of your professional experience. You have none.
Anne was eventually discharged home with the news that her cancer was not malignant and her entire tumor was resected. She was cancer-free! Regarding her diabetes, she accepted the need for treatment and was discharged home with the appropriate medication.
The Future of Building Docs
I created Building Docs as a way to reflect on the excesses of modern medical intervention and how those excesses indirectly push medicine further from its founding values. Over the last couple years, I’ve written about different topics relating to these values. However, I now wish to focus my message to a singular principle that, to me, underpins the entire foundation of medicine and health: the principle of stewardship.
Beginning early next year, I will do this in three ways. Reflecting both on the stewardship of my personal health and professional craft as well as examining the “why” behind the principle of stewardship itself.
Before discussing what’s new, let’s discuss what’s not: op-eds like “Rocks,” “The Next Step,” and “Medical Alchemy, Miracle Drug” will continue, as well as investigating Meador’s Rules for effective doctoring.
In addition to Meador’s Rules, I am starting a section called “examineHERO” where we will explore different aspects of the physical exam, how to use it to gather clues, and see how those clues point toward a diagnosis. The goal is to further hone my craft and to give you — the patient — a behind-the-scenes look at the “how’s” and “why’s” of the physical exam. I believe an informed patient is a better patient.
It’s my view that a physician must steward their own health to the best of their ability. Would you take advice from a bankrupt accountant? In some medical specialties, this is easier said than done. Nevertheless, schedules and circumstances do not negate responsibility. In response, one way I am stewarding my own health is by trying something new, trying something difficult, and trying it in nature. Join me in my journey to scale all 46 high peaks of the Adirondack Mountains and the lessons I learn along the way in “Higher Calling.”
There’s the personal in “Higher Calling,” and the professional in “examineHERO,” which simply leaves the principle itself. Why ought we focus on stewardship? To which I reply - because it’s good. The natural question follows, “Why is it good?” And it’s sister question, “Why should we strive for good?”
To answer these questions is to subscribe to a belief system. Modern medicine attempts to answer them and, in doing so, subscribes to secular humanism. I feel this foundation to be inadequate. In fact, I feel that Christianity is a much stronger belief system from which to make claims regarding the “goodness” of medicine, health, and well-being. Christianity grounds humanist claims better than secularism.
I won’t make that case here, but I will in the final section added to Building Docs called “Why I’m Christian.” In it I will discuss a range of topics, all related to Christianity — its foundations, theology, beliefs, etc — as well as it’s impact on my life and on medicine in general. All are welcome to engage with articles and ideas that are equal parts testimony, apologetics, and evangelism.
Expect new articles every three weeks starting January 2nd of next year, with paid posts sprinkled throughout.
See you next time
- Tyler
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I'm looking forward to tagging along on your journey.
Excellent! Looking forward to reading (or listening) to more of your writings in the near future. You are a very bright, young resident doctor!