EDITORIAL

 

Humility for happiness

 

 

Megan O'Connor

Department of Orthopaedic Surgery, University of KwaZulu-Natal, Durban, South Africa

 

 

 

I recently travelled abroad with a dynamic group of orthopaedic surgeons representing five nations. As these experiences are, it was an opportunity to connect with individuals from across the globe and learn different perspectives of practising the craft. I was moved by one of my colleagues' recount of an experience operating in Japan. He described how, prior to every surgery conducted there, each member of the team in theatre, and the patient, repeat the phrase 'yoroshiku onegaishimasu'. Directly translated this means 'please care for me'. What I understood this to mean is that each team member is requesting the other members to hold them accountable for their actions, and to draw attention to potentially harmful or erroneous actions, including those of the surgeon. This struck me as curious; in an environment where, as surgeons, we are conditioned to be omniscient, Japan it seems has a tradition that deliberately challenges this. To me this is an ideal of surgical practice, a culture of humility.¹

This story resonated with me, having recently been sensitised by a humbling experience. I was conducting a routine proximal row carpectomy with a trainee. I confidently demonstrated to them the proximal carpal row and started the piece-meal excision of what I believed to be the triquetrum, dismissing their increasing unease and disconcerted frowns. Fortunately, their agitation was enough to initiate a suitable number of alarm bells, and with my pride pocketed I requested fluoroscopy. I discovered a nibbled hamate, woefully not anatomically of the proximal row, and a volar subluxated proximal carpus. I was fortunate, first, that the trainee could not hide their concern; secondly, that sufficient hamate remained for the patient to suffer no ill effects from my error; and Anally, that the patient accepted my apology. This did nothing to diminish the guilt and regret I experienced reflecting on the case, because I realised the root cause to be my pride. Yet, it did prompt my interest in the practice of humility in medicine.

As I aim to develop as a surgeon, I am learning the importance of developing skills that were not addressed in my clinical training, humility being the foremost of these. Postgraduate training is focused on clinical aspects, and neglects non-technical skills, despite their established importance and inclusion as competencies in medical curricula.^2,3 A 2022 qualitative investigation found that clinicians that were voted by their peers as 'excellent', fundamentally shared the virtue of humility.⁴ This is seemingly counterintuitive. Clinicians who realise they are skilled should be confident. There is a difference, however, between confidence and the tendency towards arrogance.⁵ Indisputably, arrogance is an undesirable characteristic, but there is a view that portrays humility in a negative light too - when it is associated with lowliness, self-debasement, and appears to be weakness.^6,7 Previous reports suggest that humility represents a spectrum of behaviour, which according to Aristotle's view of all virtues, should be moderated to a golden mean.⁸ In its balanced form, humility is associated in the majority with positive connotations.⁶

What comprises the essence of humility has been the subject of extensive investigation. Humility can be understood as an intrapersonal experience, an interpersonal outward expression, or both.⁸ For practical application in orthopaedic practice, the review by Owens et al. succinctly defines humility as a: 'characteristic that emerges in social contexts that connotes (a) a manifested willingness to view oneself accurately, (b) a displayed appreciation of others' strengths and contributions, and (c) teachability.'⁶ To view oneself accurately means frankly understanding your strengths and shortcomings, actively seeking feedback, and admitting your weaknesses.^5,6,9 On appreciating others, Means et al. posited that, 'humility is an increase in the valuation of others and not a decrease in the valuation of self'.¹⁰ This is demonstrated by appreciating the contributions of others.^11,12 Finally, teachability refers to an individual's openness to learning new ideas, a desire to grow in understanding, seek out advice, and evaluate information contradictory to their current understanding. Essentially, these individuals are less cognitively rigid and have an inherent defence against developing cognitive biases.^8,13 Li et al. captured the essence of this definition for doctors: 'The humble physician tends to understand the patient's point of view, tends to recognise opportunities for improvement and tends to embrace lifelong learning.'²

So how might these defining features of humility be of benefit to our patients? Authors have argued that patients prefer a doctor that does not acknowledge their uncertainty and decides the management plan on their behalf, without placing value on their contributions.^5,9 While this may be true for some patients, investigation has shown that clinicians' humility is predictive of patient trust, patient satisfaction and compliance with treatment recommendations.^7,14 Similarly, researchers that have observed doctor-patient interactions have found that clinicians who express humility in consultation are seen as effective communicators by their patients, and their patients report higher subjective health.^15,16 Chochinov explains that if we behave as if we are more important, the patient will feel unimportant.⁹ Rather, humble clinicians encourage patient participation, do not perceive patient questions as a test of their proficiency, and participate in joint decision-making by valuing the patient's perspective.^7,17 Likewise, physicians who consult other colleagues or declare knowledge gaps seem more credible and garner the trust of patients who understand that being uncertain does not mean being incompetent.⁷ In fact, justification of this perception has been explored. A Canadian study found a correlation between final exam marks and requests for second opinion and referrals: the higher the exam scores, the more likely the clinicians were to refer patients for a second opinion or specialist care.¹⁸

In addition to having satisfied patients, physicians may themselves benefit from humble interactions. Chochinov goes on to suggest that these exchanges may decrease the risk of physician burnout and potentially increase job satisfaction.⁹ This extends into personal relationships too; humility is shown to be important in developing healthy relationships, and is associated with an increased capacity for forgiveness and willingness to reconcile.^9,19-22 These improved social and patient relationships are consistent then with the improved psychological health and well-being that humble individuals experience.^23,24 More than an enhanced sense of well-being, humble individuals experience reduced negative psychological states such as anxiety and depression.²⁴ This is important to consider in light of a recent editorial addressing the concern of surgical error in orthopaedics.²⁵ It takes humility to acknowledge that we can, and will, make mistakes.⁹ It also takes a healthy dose of humility to recognise knowledge deficits and admit fault, and still more humility to motivate the ongoing quest to learn and improve one's skills.^9,26 We should be open to revisiting dogma, testing our previously held beliefs and adapt accordingly.⁹

There may be broad implications of encultured humility for the orthopaedic community too. It has been observed that individuals promoted to a position of power (such as surgeons) tend to dismiss the ideas of their junior peers.²⁷ Arrogant doctors can increase work environment stress and lower morale, which can result in poor staff retention.²⁸ Conversely, Owens et al. in their investigation of humility in organisations, found that a humble leader improved team engagement, contribution, individual performance, job satisfaction and retention of staff.⁶

These findings are all very promising, but do individuals have the capacity to foster humility? In psychological terms it is understood that humility is both a trait - a characteristic inherent to us that we are born with - but also a state: a virtue that can change depending on the social context.^8,24 This means that we can cultivate humility with deliberate practice. In fact, humility can be developed, monitored and measured.^6,8 Psychologists have explored case scenario simulations and introspective reflective writing as effective tools to develop the attribute.^8,29,30 These may be useful in the long term, but a more pragmatic suggestion for immediate adoption is to identify a humble mentor.¹ You are likely to recognise a behaviour, action or attitude that you have adopted from someone you admire or respect. Therein lies the grounds for the mentorship model. Our mentor and social relationship choices will affect our ability to learn and practise our profession with humility.^1,2,8,30

It was a respected senior colleague who mentored me through my nibbled hamate experience, and fortunately for me he is a paragon of humility. Together with his support and the painful realisation that there will always be room for growth, I can now appreciate how humility is central to my practice and life. Cognisant that I'm not alone in this experience, I consider an honest reflection on how humility can change patient interactions, mentoring exchanges and personal relationships valuable to each of us. I'm inspired by the sage words of Confucius: 'The superior man is distressed by the limitations of his ability; he is not distressed by the fact that men do not recognise the ability that he has.'

 

References

1. Sreenivasan S and Weinberger L. Physician's humility. How does it affect patients' confidence in their doctor? Psychol Today 2018. https://www.psychologytoday.com/gb/blog/emotional-nourishment/201802/physicians-humility        [ Links ]

2. Li JT. Humility and the practice of medicine. Mayo Clin Proc 1999;74:529-30. https://doi.org/10.4065/74.5.529        [ Links ]

3. Gruppen LD. Humility and respect: core values in medical education. Med Educ 2014;48:53- 58. https://doi.org/10.1111/medu.12269        [ Links ]

4. Wadhwa A, Mahant S. Humility in medical practice: a qualitative study of peer-nominated excellent clinicians. BMC Med Educ 2022;22:88. 20220209. https://doi.org/10.1186/s12909-022-03146-8        [ Links ]

5. Coulehan J. 'A gentle and humane temper': humility in medicine. Perspect Biol Med 2011;54:206-16. https://doi.org/10.1353/pbm.2011.0017        [ Links ]

6. Owens BP, Johnson MD, Mitchell TR. Expressed humility in organizations: Implications for performance, teams, and leadership. Organ Sci. 2013;24:1517-38. https://doi.org/10.1287/orsc.1120.0795        [ Links ]

7. Huynh HP, Dicke-Bohmann A. Humble doctors, healthy patients? Exploring the relationships between clinician humility and patient satisfaction, trust, and health status. Patient Educ Couns. 2020;103:173-79. 20190802. https://doi.org/10.1016/jpec.2019.07.022        [ Links ]

8. Porter T, Elnakouri A, Meyers EA, et al. Predictors and consequences of intellectual humility. Nat Rev Psycholgy 2022;1:524-36. https://doi.org/10.1038/s44159-022-00081-9        [ Links ]

9. Chochinov HM. Humility and the practice of medicine: tasting humble pie. CMAJ 2010;182:1217-18. 20100705. https://doi.org/10.1503/cmaj.100874        [ Links ]

10. Means JR, Wilson GL, Sturm C, et al. Humility as a psychotherapeutic formulation. Couns Psychol Q 1990;3:211-15. https://doi.org/10.1080/09515079008254249        [ Links ]

11. Tangney JP. Humility. Oxford handbook of positive psychology, 2nd ed. New York, NY, US: Oxford University Press, 2009, pp.483-90.         [ Links ]

12. Exline JJ, Geyer AL. Perceptions of humility: A preliminary study. Self and Identity 2004;3:95-114. https://doi.org/10.1080/13576500342000077        [ Links ]

13. Tangney J. Humility: Theoretical perspectives, empirical findings and directions for future research. J Soc Clin Psychol. 2000;19:70-82. https://doi.org/10.1521/jscp.2000.19.L70        [ Links ]

14. Barbosa CD, Balp MM, Kulich K, et al. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. Article. https://doi.org/10.2147/PPA.S24752        [ Links ]

15. Ruberton PM, Huynh HP, Miller TA, et al. The relationship between physician humility, physician-patient communication, and patient health. Patient Educ Couns. 2016;99:1138-45. https://doi.org/10.1016/j.pec.2016.01.012        [ Links ]

16. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ. 1995;152:1423-33.         [ Links ]

17. Gallagher SM. Paternalism in healthcare decision making. Ostomy Wound Manage. 1998;44:22, 24-25.         [ Links ]

18. Tamblyn R, Abrahamowicz M, Brailovsky C, et al. Association between licensing examination scores and resource use and quality of care in primary care practice. JAMA. 1998;280:989-96. https://doi.org/10.1001/jama.280.11.989        [ Links ]

19. Ludwig JM, Schumann K, Porter T. Humble and apologetic? Predicting apology quality with intellectual and general humility. Pers Individ Differ. 2022;188:111477. https://doi.org/10.1016/j.paid.2021.111477        [ Links ]

20. McElroy SE, Rice KG, Davis DE, et al. Intellectual humility: scale development and theoretical elaborations in the context of religious leadership. J Psychol Theol. 2014;42:19-30. https://doi.org/10.1177/009164711404200103        [ Links ]

21. Peters AS, Rowatt WC, Johnson MK. Associations between dispositional humility and social relationship quality. Psychology. 2011;2:155-61. https://doi.org/10.4236/psych.2011.23025        [ Links ]

22. Onody AP, Woodyatt L, Wenzel M, et al. Humility and its relationship to self-condemnation, defensiveness and self-forgiveness following interpersonal transgressions. J Psychol Theol. 2020;48:118-30. https://doi.org/10.1177/0091647120911111        [ Links ]

23. Vaillant GE. The wisdom of the ego. Cambridge, MA, US: Harvard University Press, 1995, p.394-94.         [ Links ]

24. Zalewska J, Zawadzka AM. Can humility bring happiness in life? The relationship between life aspirations, subjective well-being, and humility. Annals of Psychol. 2013;16(3):433-49.         [ Links ]

25. Rajah L. Navigating adversity: the orthopaedic surgeon and complications. SA Orthop J. 2023;22(2):65-66.         [ Links ]

26. Wright PI. Cultural humility in the practice of applied behavior analysis. Behav Anal Pract. 2019;12:805-809. 20191018. https://doi.org/10.1007/s40617-019-00343-8        [ Links ]

27. Kipnis D. Does power corrupt? J Pers Soc Psychol. 1972;24:33-41. https://doi.org/10.1037/h0033390        [ Links ]

28. Berger AS. Arrogance among physicians. Acad Med. 2002;77:145-47. https://doi.org/10.1097/00001888-200202000-00010        [ Links ]

29. Zavala F. On humility in medicine. Florida Atlantic University, The Wilkes Honors College, 2022.         [ Links ]

30. Peña I and Koch J. Teaching Intellectual Humility Is Essential in Preparing Collaborative Future Pharmacists. Am J Pharm Educ. 2021;85:8444. https://doi.org/10.5688/ajpe8444        [ Links ]

 

 

* Corresponding author: oconnorm1@ukzn.ac.za