A Way Out of Burnout: Cultivating Differentiated Leadership Through Lament

Some interesting (and provocative) thoughts from the world of church leadership. “Lament” is not prominent in our culture anymore, at least not in our official culture… and one could wonder how to translate these ideas into a secular setting. Nevertheless, there is much to ponder here and I would feel that all in leadership positions – or roles susceptible to burnout – could benefit from reading this, whether they have religious faith or not.

I found the following paragraphs (of what is a long paper) especially resonated:

 

Leaders who are most likely to function poorly physically or emotionally are those who have failed to maintain a well-differentiated position. Either they have accepted the blame owing to irresponsibility and constant criticism of others, or they have gotten themselves into an overfunctioning position (that is, they tried too hard) and rushed in where angels and fools both fear to tread.[12]

Many programs often aim to cure clergy burnout by offering retreats that focus on rest and relaxation. However, Friedman asserts, “Resting and refreshment do not change triangles. Furthermore, because these programs focus on the burned-out ‘family’ member, they can actually add to his or her burden if such individuals are inclined to be soul searchers to begin with.”[13] These same soul-searching and empathetic clergy are vulnerable to seeing the overwhelming burdens that they carry for others as crosses that they ought to bear. Friedman calls this way of thinking “sheer theological camouflage for an ineffective immune system.”[14] When clergy bear other people’s burdens, they are encouraging others not to take personal responsibility. And often in bearing other people’s burdens, clergy easily tend to ignore their own “burdens” (ie. marriage issues, financial problems, etc.) and thus fail to be personally responsible for themselves.

 

London also discusses how “lament” and in some ways “passing the buck onto God” has Biblical roots:

God responds with sympathy to Jesus’ ad deum accusation and lament. Furthermore, one may easily interpret the empty tomb at the end of the Gospel as a sign of God’s ultimate response to Jesus’ lament: the resurrection (Mark 16:4-7). In the psalms of lament and in the cry of dereliction, we see that God does not respond with hostility but with a sympathetic openness to our struggle, our need for someone to blame and, in the words of Walter Brueggemann, our “genuine covenant interaction.”[34] God responds with sympathetic openness to Jesus’ ad duem accusation and then dispels the blame and emotional burden that no human could ever bear. Jesus receives the blame that humans cast upon him and then gives it to God who receives it, absorbs it and dispels it. Jesus let go of the blame by giving it to God. His cry of dereliction became his cry for differentiation. In this way, Jesus serves as a role model for leaders who receive blame from others and then need to differentiate in order to not take accusations personally. By practicing lament, leaders can turn the ad hominem accusations against themselves into ad deum accusations against God, who responds with sympathetic openness while receiving and dispelling the blame. Moreover, leaders can respond with empathy to the suffering of others, knowing that they will not have to bear the emotional burden that they have taken on, indefinitely. They can let go of the emotional burden by passing it on to God through the practice of lament.

This “passing of the buck” to God does not encourage irresponsibility. Rather, it gives the emotional baggage away to the only One who can truly bear it, thus freeing the other to take personal responsibility, without feeling weighed down by unbearable burdens. With this practice, a pastor can therefore receive blame and emotional baggage from parishioners in a pastoral setting because they can differentiate through lament. They can take the blame like Jesus because they, like Jesus, can also pass the buck to God through ad deum accusation. Eventually, the pastor will want to teach the parishioners to redirect their human need to blame onto God as well so as to occlude the cycle of scapegoating in the community.[

 

Daniel DeForest London

This is the final paper I wrote for the class “Leading Through Lament” with Dr. Donn Morgan at the Church Divinity School of the Pacific.

INTRODUCTION

On August 1, 2010, New York Times published an article titled “Taking a Break From the Lord’s Work,” which began with the following statements:  “Members of the clergy now suffer from obesity, hypertension and depression at rates higher than most Americans. In the last decade, their use of antidepressants has risen, while their life expectancy has fallen. Many would change jobs if they could.”[1] Although these are troubling reports, some of the statistics that came out of a study conducted by Fuller Theological Seminary in the late 1980s prove more disturbing: “80 percent [of pastors] believe that pastoral ministry is affecting their families negatively, 90 percent felt they were not adequately trained to cope with the ministry demands placed upon them, 70 percent…

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Marcus Aurelius: reflection good enough for an emperor but is it good enough for medicine?

Sati Heer-Stavert very kindly asked my permission to link to the paper I wrote a while back on Marcus Aurelius, stoicism and reflective practice – here is the post that has resulted which I am very impressed by! Certainly Sati has provided an excellent framework to prompt students and learners to reflect on what reflection means and what the obstacles to it are….

UNEXAMINED MEDICINE

Reflection is an important part of training, appraisal and revalidation for doctors based in the UK. However, for many doctors the very thought of reflection can cause feelings of frustration, non-engagement or even rejection. Where did we go wrong?

Learning objectives

1. Consider the definition of reflection used in medicine

2. Understand how reflection can be assessed

3. Encourage you to read Meditations by Marcus Aurelius

Oh no! A patient has complained about your refusal to supply antibiotics for a cold. Wow! This would make a really good entry in your learning portfolio:

“That men of a certain type should behave as they do is inevitable. To wish it otherwise were to wish the fig-tree would not yield its juice. In any case, remember that in a very little while both you and he will be dead, and your very names will quickly be forgotten.”

You have to respond to…

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The individual, “characters” and social roles

Recently I read Alasdair MacIntyre’s “After Virtue.” On my other blog I have posted a range of quotes from that I found stimulating and provocative. One chapter, “Emotivism: Social Content and Social Context”, draws heavily on the work of Erving Goffman and also Philip Rieff’s work on therapeutic culture. In this chapter, which I found possibly the least convincing of the book (though perhaps for my own reason), MacIntyre discusses the notion of moral “characters” – the Therapist, the Rich Aesthete, the Manager. Most of his argument is around the Manager as character, in what is an assault on the idea of managerial culture and expertise.  Characters are not the same as social roles:

Characters specified thus must not be confused with social roles in general. For they are a very special type of social role which places a certain kind of moral constraint on the personality of those who inhabit them in a way in which many other social roles do not. I choose the word ‘character’ for them precisely because of the way it links dramatic and moral associations. Many modern occupational roles – that of a dentist or a garbage collector, for example – are not characters in the way that a modern bureaucratic manager is.

aftervirtue

For MacIntyre, the Therapist is one of those characters with dramatic and moral associations, although with a caveat you don’t always find in this kind of discourse:

It is of course important that in our culture the concept of the therapeutic has been given application far beyond the sphere of psychological medicine in which it obviously has its legitimate place… Philip Rieff has documented with devastating effect a number of the ways in which truth has been displaced as a value and replaced by psychological effectiveness.

This specific point is not one I am going to discuss at length now. The passage from MacIntyre I have found most helpful in this chapter – and one which perhaps offers a resolution of the somewhat uncomfortable air of “being a Character” is the following:

Contrast the quite different way in which a certain type of social role may embody beliefs so that the ideas, theories and doctrines expressed in and presupposed by the role may at least on some occasions be quite other than the ideas, theories and doctrines believed by the individual who inhabits the role. A Catholic priest in virtue of his role officiates at the mass, performs other rites and ceremonies and takes part in a variety of activities which embody or presuppose, implicitly or explictly, the beliefs of Catholic Christianity. Yet a particular ordained individual who does all these things may have lost his faith and his own beliefs may be quite other than and at variance with those expressed in the actions presented by his role. The same type of distinction between role and individual can be drawn in many other cases. [MacIntyre describes a trade union official who in his role acts in a way that “generally and characteristically presupposes that trade union goals … are legitimate goals” but who “may believe that trade unions are merely instruments for domesticating and corrupting the working class by diverting them from any interest in revolution.

As a psychiatrist, one is very often confronted with a certain response; in practice, in daily life, even in literature and the media. recently I read Patrick Leigh Fermor’s book on monasticism, A Time to Keep Silence.

timetokeepsilenceIn it he suddenly imagines a discourse between “a psychiatrist” and the monks, in which the psychiatrist seems keen to dismiss their lives as an expression of various neuroses etc. I can’t imagine, as a psychiatrist, ever doing such a thing; partly Leigh Fermor is reflecting the norms of his time (the 1950s). I have found it helpful, since reading MacIntyre’s passage, to reflect on the distinction between myself as the individual people encounter, and the social role and character they expect to encounter.

‘Wrestle to be the man philosophy wished to make you’: Marcus Aurelius, reflective practitioner. Reflective Practice. 10.4 (2009): 429-436. Part 2

As outlined above, many of the sections of each book are epigrammatic and abstract. This is frustrating for the historian, for the personal diary of a Roman Emperor is, one would imagine, a priceless primary source. It also makes it difficult to identify which, if any, specific incidents may have inspired ‘awareness of unsettling thoughts’, and the subsequent critical analysis as outlined in Raw et al.’s (2005) model. Many of the sections are general moral reflections, exhortations to the self to live up to one’s own standards. Phrases such as ‘always remember’ recur some 40 times over the course of the text.
Some sections deal directly with his role as ruler:

Take heed not to be transformed into a Caesar, not to be dipped in the purple dye, for it does happen. Keep yourself therefore, simple, good, pure, grave, unaffected, the friend of justice, religious, kind, affectionate, strong for your proper work. Wrestle to be the man philosophy wished to make you. Reverence the gods, save men. Life is brief; there is but one harvest of earthly existence, a holy disposition and neighborly acts. In all things like a pupil of Antoninus; his energy on behalf of what was done in accord with reason, his equability everywhere, his serene expression, his sweetness, his disdain of glory, his ambition to grasp affairs. (Book VI, Section 30)
This section is full of imperatives – ‘take heed’, ‘keep yourself’, ‘wrestle to be the man’, ‘reverence’ – before returning to the example of his foster father and imperial predecessor. This recurs often in the Meditations. As outlined above, the first book of the Meditations is different in tone and structure from the others, being a catalogue of people to whom Marcus is grateful, and what he is grateful for. By some distance the longest of these sections is on Antoninus. Thus it could be considered that Antoninus became for Marcus an ideal Emperor to be emulated, as close as one could get to the Stoic ‘sage.’ The section quoted immediately above continues:

Also, how he let nothing at all pass without first looking well into it and understanding it clearly; how he would suffer those who blamed him unjustly, not blaming them in return; how he refused to entertain slander; how exactly he scrutinised men’s characters and actions, was not given to reproach, not alarmed by rumour, not suspicious, not affecting to be wise; how he was content with little, in lodging, in his bed, in dress, in food, in service, how he loved work and was long‐suffering.
Thus Antoninus reflected the Stoic conception of virtue. As a reflective practitioner, Marcus returned the examples of Antonius and of the virtue of ‘philosophy’ as touchstones. One could consider that they provide the framework for critical analysis of the situations Marcus was faced with that provoked reflective thought. Not surprisingly, another repeated theme is that it is possible to live a philosophical life as an Emperor. It was often felt that philosophy and the eminence that went with being Emperor were diametrically opposed. Some of this attitude derived from philosophers – it was the view of the Epicureans that involvement in public affairs inevitably brought pain. Political actors, too, were often disdainful of philosophy – the view of Agrippina, Nero’s mother, as reported in Suetonius, was that philosophy was a hindrance to a future ruler (cited in Rutherford, 1989b, p. 178).
Marcus often returns to this topic:

As are your repeated imaginations so will your soul be, for the soul is dyed by its imaginations. Dye it, then, in a succession of imaginations like these: for instance, where it is possible to live, there also it is possible to live well: but it is possible to live in a palace, therefore it is also possible to live well in a palace. (Book V, Section 16)
This tension was obviously one of the main preoccupations of Marcus. As outlined above, self‐improvement was key to Stoic practice, and as Emperor clearly the pressures of affairs seemed to militate against this. Marcus uses a maternal metaphor to reconcile himself to this tension:
Had you a step‐mother and a mother at the same time, you would wait upon the former but still be continually returning to your mother. This is now what the palace and your philosophy are to you. Return to her again and again, and set up your rest in her, on whose account that other life appears tolerable to you and you tolerable in it. (Book VI, Section 12)
It is noteworthy that at the end of this section Marcus accuses himself – looking beyond difficulty in the court to difficulties in his inner self. Immersion in his ‘mother’, philosophy, will make him ‘tolerable’ in the world of the court. Therefore we see Marcus repeatedly reflecting on his role as Emperor, and trying to see beyond his immediate reactions and frustrations.
Another saying is also significant, as it sees Marcus going beyond this tension to identify his role as being ideally suited for philosophical practice:

How vividly it strikes you that no other calling in life is so fitted for the practice of philosophy as this in which you now find yourself. (Book XI, Section 7)
To return to Tight’s (1998) concern with the potential of imposed reflective practice to become a stale chore, within the professions it is important not only that reflective practice occur, but that it be seen to occur. Reflective diaries that can be read and scrutinised, supervision sessions that can be counted and minuted – all ultimately for the sake of proving that reflection exists. Marcus Aurelius wrote what would later become known as his Meditations without any external compulsion. There was no authority demanding evidence of reflective practice.
Furthermore, some of the pressures that Marcus describes of sheer busy‐ness leading to a tension between the workaday world of administrating the empire and the reflective work of philosophy are obviously familiar to practitioners today. While reflective practice is increasingly popular amongst medical professionals, it is still viewed with a certain amount of reserve by many. The tendency is to see it as a luxury, at best an optional extra, at worst a distraction from ‘real work.’ Marcus’Meditations show that this tension has always been with us, and that Marcus himself drew strength and support from philosophical practice.
It will strike some readers as ironic that I am using a Roman Emperor as an example and exemplar of a reflective practitioner. Marcus presided over mass slavery and the persecution of Christians. He was not simply an imperialist – he was Empire. It may seem ludicrous to describe being Emperor as a profession in the same sense we use it when discussing contemporary reflective practice in health care or in other areas. Whatever the power of the professions, few professionals have anything like the power of a Marcus Aurelius.
Marcus himself, however, reminds us repeatedly of his humanity and our common humanity with him. He does not refer to even the most virtuous emperors as divine, writing that:

In the first place, be not troubled, for all things are according to Universal Nature, and in a little while you will be no one and nowhere, even as Hadrian and Augustus are no more. (Book VIII, Section 5)
The Marcus that emerges is not saintly or otherworldly – as Rutherford remarks in the introduction to his edition of theMeditations, ‘from his own words we can deduce that he often found it hard to restrain his temper, and hence that the many references to anger in the Meditations are not merely conventional’ (Rutherford, 1989b, p. xvii). Many of the values that were universally held in his society are repugnant to us today. Nevertheless, he emerges from the Meditations as a man reflecting on his work and striving to improve it and himself – a model of the reflective practitioner.
One could identify certain characteristics of his writings that may be useful to other reflective practitioners. For instance, he uses Antoninus as a role model and returns repeatedly to his example. Thus, modelling effective practitioners, often suggested as a framework for professional reflective practice, has a precedent. He also demonstrates great personal commitment to his reflective practice, and works within the framework of his overall philosophical approach to life. He also manages to identify the tensions between his imperial role and philosophical inclinations and, while acknowledging them, comes to see how these roles are complementary.

REFERENCES

  • 1. Brunt, P.A. 1974. Marcus Aurelius in his Meditations. Journal of Roman Studies, 64: 1–20.
  • 2. Epictetus. 1928. The discourses as reported by Arrian, the manual, and fragments, Edited by: Oldfather, W.A. Harvard, MA: Loeb Classics.
  • 3. Foucault, M. 1984. The history of sexuality: Volume 3 – The care of the self, London: Penguin Books.
  • 4. Gibbon, E. 2000. The history of the decline and fall of the Roman Empire, Edited by: Wormesley, D. Harmondsworth, , UK: Penguin.
  • 5. Hadot, P. 1990. Forms of life and forms of discourse in ancient philosophy. Critical Inquiry, 16(3): 483–505.
  • 6. Hadot, P. 1995. Philosophy as a way of life, Oxford: Blackwell.
  • 7. Hadot, P. 2001. The inner citadel: The Meditations of Marcus Aurelius, Cambridge, MA: Harvard University Press.
  • 8. Machiavelli, N. 1983. Discourses on the first decade of Titus Livy, Edited by: Walker, L.J., Richardson, B. and Crick, B. Harmondsworth, , UK: Penguin.
  • 9. Nordenfelt, L. 1997. The stoic conception of mental disorder: The case of Cicero. Philosophy, Psychiatry and Psychology, 4: 285–291.
  • 10. Raw, J., Brigden, D. and Gupta, R. 2005. Reflective diaries in medical practice. Reflective Practice, 6(1): 165–169.
  • 11. Rutherford, R.B. 1989a. The Meditations of Marcus Aurelius Antoninus: A study, Oxford: Oxford University Press.
  • 12. Rutherford, R.B. and Farquharson, A.S.L., eds. 1989b. The Meditations of Marcus Aurelius Antoninus, Oxford: Oxford University Press.
  • 13. Schön, D. 1987. The reflective practitioner: How professionals think in action, New York: Basic Books.
  • 14. Sellars, J. 1996. Stoicism, Chesham, , UK: Acumen.
  • 15. Tight, M. 1998. Lifelong learning: Opportunity or compulsion?. British Journal of Educational Studies, 46(3): 251–263.[Taylor & Francis Online], [Web of Science ®]

‘Wrestle to be the man philosophy wished to make you’: Marcus Aurelius, reflective practitioner. Reflective Practice. 10.4 (2009): 429-436. Part 1

Re-reading this I am struck with my anachronistic hubris in trying to claim Marcus Aurelius as a some kind of trainee emperor scribbling away his reflections. Mary Beard had a piece in the TLS pouring scorn on the idea of the “philosopher-emperor” and I am pretty sure would disapprove of this piece. And my respect for the profession of history is such I cringe at my no doubt many errors.
However, one of the wonders of literature is that it allows a dialogue with the dead and perhaps the connections are not so forced as all that.  I also find the tension between a regulatory demand for reflection and the actual practice of reflection an even more germane one at this stage in my career. Regulators are increasingly demanding what sound like benign, motherhood-and-apple-pie type textual interventions, which in practice turn into form filling chores, much resented.

The original paper is here

Abstract

The Meditations of the Roman Emperor Marcus Aurelius Antoninus have been read by historians, philosophers and general readers as a text of Stoic philosophy and an insight into the mind of an imperial ruler. In this paper the author discusses aspects of theMeditations from the point of view of reflective practice, positing that Marcus Aurelius is in some ways an exemplar of reflective practice. He discusses his own professional background and concerns within it about reflective practice being a compulsory or imposed part of training. A description of Stoic philosophy follows, with an emphasis on its ethical and moral teachings. The work of Pierre Hadot and Michel Foucault on ‘the care of the self’ and the importance of practice in Ancient Philosophy is discussed. Extracts from the Meditations which can be read as reflective work by Marcus Aurelius on his ‘professional’ role as Emperor are presented and discussed. Finally the relevance of Marcus Aurelius today, and his possible role as an exemplar of reflective practice freely undertaken for its own sake, are discussed.
The Roman Emperor Marcus Aurelius, named at birth Marcus Annius Verus, is now remembered primarily as the author of what have become known as the Meditations. These reflections were written on campaign in the later years of Marcus’ life. The title Meditations is a later addition – the title on the manuscripts that survive is Tά εỉς έαυτόν, transliterated to Ta eis heauton (‘to himself’). In this paper, I will examine the Meditations and Marcus’ reflections on his role as Emperor as an exemplar of reflective practice. This is in the context of Stoic philosophy, and a wider concern in the ancient world with self‐cultivation by means of reflection and diary keeping – I also wish to provide a historical context for reflective practice work. I will use this to reflect on practices in my own profession of medicine and suggest that Marcus Aurelius is a useful role model for reflective practice.
Before discussing the Meditations as a prototypical reflective practice text, I will discuss reflective practice from my own perspective. I am from a medical background, at time of writing a Special Lecturer and Senior Registrar in Psychiatry. Reflective practice has become popular within the professions; one could argue that reflective practice is something that has always been implicit in them, as an extension of the duty to ‘keep up to date.’ Another view would see it as being imposed by regulatory and other agencies, representing a public distrust of professional authority.
A key text in reflective practice in its modern incarnation is Schön’s 1987 book Educating the Reflective Practitioner. In the book, Schön quotes the sociologist Everett Hughes:

In return for access to their [the professions’] extraordinary knowledge in matters of great human importance, society has granted them a mandate for social control in their fields of specialization, a high degree of autonomy in their practice, and a license to determine who shall assume the mantle of professional authority. But in the current climate of criticism, controversy, and dissatisfaction, the bargain is coming unstuck. When the professions’ claim to extraordinary knowledge is so much in question, why should we continue to grant them extraordinary rights and privileges? (Schön, 1987, p.7)
The power of the professions and the power of the academy are continually questioned in modern society. Medicine in particular has lost much of its privileged status. Scandals such as the Bristol, Alder Hey and Shipman cases in the UK, the Michael Neary case in the Republic of Ireland, and contaminated blood products in a number of jurisdictions, have led to a much greater public expectation of external scrutiny of medical authority. Reflective practice may offer an answer to Hughes’ question.
Various models of reflective practice are influential in biomedicine. One is that described by Raw, Brigden, and Gupta (2005) consisting of:
an awareness of unsettling thoughts/feelings about an event or events;

critical analysis of the situation; and

the development of a new perspective on the situation.

This approach has been incorporated within professional education in the establishment of formal mentoring and supervision schemes, and the formal use of reflective practice diaries. Reflective practices are increasingly built into both undergraduate medical education and postgraduate training. This reflects a concern in medical education with fostering deeper, lifelong learning patterns. Medical students were, traditionally, seen as particularly prone to exam‐focused, ‘just in time’ learning.
Concern has arisen within medical educational research about the possible effects of embedding reflective practice in work and the framework of regulatory supervision. This concern is well articulated by Tight (1998). Can this lead to a joylessness and rote approach to reflection, a sense that rather than being something that can lead to professional and personal growth and development, it is simply a means of control by external agencies? With this question in mind, I wish to return to discussing the philosophical background to the Meditations.
Cicero, the Roman orator and political figure of the first century BC, whose philosophical writings are sympathetic to Stoicism, described philosophy in his Tusculan Disputations as animi medicina, or ‘medicine for the soul’ (Nordenfelt, 1997). Ancient Philosophers saw their role as discerning and teaching the right way to live, in a way that modern academic philosophy, ethics apart, does not.
The Meditations are often described as a text of Stoic philosophy. ‘Stoic’ in modern contemporary usage is synonymous with ‘repressed’ and has pejorative connotations. This was very different from what the Stoics actually taught. Zeno of Citium (334 BC–262 BC) started the Stoic school of philosophy around 301 BC, teaching in the stoa poikile or ‘painted porch’ of his house in Athens, from whence the word ‘Stoic’ derived. Stoic thought (Sellars, 1996) provided a holistic, unified worldview, with a threefold approach of formal logic, materialist physics and naturalistic ethics. It is for their ethical writings and teachings that the Stoics are now primarily remembered, but an equal emphasis was placed in Stoic teaching on a view of logic which held that certainty in knowledge could be achieved through the use of reason, and a cosmology which posited the universe as a material substance capable of reason and known as ‘God’ or ‘Nature.’
As mentioned above, it is in the ethical field that the Stoics are most remembered and most misunderstood. Rather than encouraging an emotion‐free approach to life, enduring for the sake of enduring, they proposed an approach based on απαθεια (apatheia) which is generally translated as ‘apathy’ – something very different from modern use of the word.Apatheia implies clarity of thought and judgement rather than indifference. They argued that we should attempt to focus on what is under our control, and what is not under our control is ‘indifferent.’ It is possible to have ‘preferred indifferents’, things not under our control but desirable, such as health or good reputation. Stoic thought postulated an ideal ‘sage’ to which we could aspire, although no one had actually achieved that level of apatheia and indifference to indifferents.
The Meditations are not straightforwardly ‘Stoic’, and incorporate elements of Platonism and Epicureanism as well. They generally avoid technical discussion of Stoic or other approaches to questions such as the nature of being. They have been divided, traditionally, into 12 ‘books’, although the structure of the original manuscript is considerably looser. The first of these books is quite different from the rest, consisting of a catalogue of significant people in Marcus’ life and what he has learned or derived from each. The other books compile his own reflections in various ‘sections’, not organised with any evident over‐riding scheme or argument. They are generalised, rather than dealing with specific instances. Many allude to quotations and historical incidents, some of which are unknown to us.
The Meditations, I argue, reflect a key argument of Stoic thought – that apatheia, the characteristic of the wise man or sage, could be cultivated and developed. The Ancient Greeks had a concept of meditation or practice from early in their cultural history. The original Muses (female personifications of various attributes) were three – Mneme (memory), Aoite (song) and Melete (meditation/practice) – before later becoming the more familiar nine. The first identifiable philosophers of Ancient Greece, the Pre‐Socratices and the Sophists, also discussed the importance of practice and reflection. The Sophist Isocrates stated that the exercise of philosophy (philosophias askesis) is for the soul what medical attention is for the body. The word ‘ascetic’ is derived from askesis, and in a now familiar pattern had a broader meaning than the current sense of the abjuration of physical comfort.
The French philosopher and classicist Pierre Hadot described how Ancient Philosophical traditions distinguished between philosophy as philo Sophia (‘the love of Wisdom’) and discourse about philosophy as practice (Hadot, 1990, 1995, 2001). The Stoics, for Hadot, exemplified the ancient tendency to focus on practice rather than speculation, or debate. Practice leads to the cultivation of wisdom and the development of a spiritual life. Epictetus writes ‘the lecture room of the philosopher is a hospital ward’ (Epictetus, 1928, 3.23.27) and the Stoics, like other Ancient Philosophers, saw their work as being the cure of souls. As mentioned above, the Stoics did have a cosmological and metaphysical system, which loomed as large in their work as the ethical one – but the writings of Stoics such as Seneca, Cicero and Marcus Aurelius (all primarily public figures rather than philosophers) focused on practical ethics.
Another French thinker who particularly attended to Stoic thought (and has been highly influential) was Michel Foucault. In his later works, Foucault explored the creation of ‘a technology of the self’ (Foucault, 1984) and, while his starting point was Socrates’ injunction that one should ‘take care of oneself’, he mainly focused on the Stoics as the Ancient Philosophers who developed techniques for actually doing this. ‘Technology of the self’, discussed in the third volume of Foucault’s unfinished magnum opus The History of Sexuality (Foucault, 1984), referred to the techniques through which human beings constitute themselves. Foucault argues that, as subjects, we are perpetually engaged in defining and producing our own ethical self‐understanding. Foucault discusses at length the υποµνηµα – or Hypomnema – a Greek term that can be translated in many ways – as a reminder, a note, a copy, a public record, and other terms. Foucault uses the word in the sense of a note, and discusses it in the context of Seneca’s discipline of self‐knowledge.
Foucault’s and Hadot’s view of Stoicism as being concerned with ‘practice’ brings us to the actual practices that were involved in developing apatheia. Epictetus advised his adherents ‘to exercise daily to meet the impressions of our senses’ (Epictetus,1928, 3.8.1). In his writings, we find question‐and‐answer pairs that serve to limit the perceived consequences of any particular occurrence. For instance, ‘His ship is lost. What happened? His ship is lost. He was carried off to prison. What happened? He was carried off to prison.’
Meditations (all citations to this text that follow are from the Oxford World’s Classics Edition of Rutherford, 1990) was written as a form of practice of Stoic discipline, with the headings of individual parts of the manuscript indicating that entries were written at particular stages of a military campaign. Rutherford observes that they

are not predominately reflections, pensées, or miniature essays; Marcus tends to be talking to and at himself. The aim of the Meditations is therapeutic: to revive and bring home to himself, in suitably striking and memorable form, the moral truths that the author has accepted in the past. (Rutherford, 1989a, 13)
Who was Marcus Aurelius? Marcus Annius Verus was born in 121 AD. His father, Verus, died when Marcus was young, and he was raised primarily by his grandfather, also Marcus Annius Verus, who was an influential figure related to the Emperor Hadrian. Hadrian punningly nicknamed Marcus verisissimus – ‘the truest’ – and regarded him as something of a favourite, prevailing upon his heir Antoninus Pius to adopt the boy in 138.
On the death of Hadrian, Marcus was betrothed to Antoninus’ daughter (and his own cousin) Faustina. On his accession as Emperor, Marcus requested that the Senate install his adoptive brother Lucius as Co‐Emperor. Lucius took the name Verus as Emperor and would earn a reputation as a playboy in later literature, partly as a rhetorical foil to the serious Marcus. However, Marcus’ diaries and correspondence reveal affection and respect for his Co‐Emperor, who pre‐deceased Marcus in 169.
The five emperors up to and including Marcus became later known as the Five Good Emperors. This phrase is derived from Machiavelli’s Discourses, as an illustration of the superiority of succession by adoption (implying a degree of judgement and merit) over succession purely based on birth (Machiavelli, 1983). Edward Gibbon, in his History of the Decline and Fall of the Roman Empire, wrote that

If a man were called to fix the period in the history of the world during which the condition of the human race was most happy and prosperous, he would, without hesitation, name that which elapsed from the death of Domitianto the accession of Commodus [Marcus’ son and heir]. (Gibbon, 2000, I:70)
During his reign, the Empire was more or less constantly beset by wars. From the 160s, Germanic tribes began launching incursions into Gaul and across the Danube. After Verus’ death, the rest of Marcus’ reign was spent on campaign. The main tribal antagonists of the Romans were the Marcomanni and Quadi, and the term ‘Marcomannic Wars’ has been given to the overall conflict. Although a Roman victory in 176 AD saw a triumph for Marcus, the respite was brief and in 177 AD a second Marcomannic war began. Over the course of this campaign, Marcus Aurelius fell ill with chickenpox and died in Vindobona (modern Vienna) on 17 March 180.
The Meditations were unknown during his lifetime and until the fourth century. Brunt (1974) argues that as the Meditations can often be cryptic and allude to what are presumably personal events, as well as repetitive and unsystematic in their treatment of various themes, it is nearly certain that they were written for Marcus himself rather than an external readership.

About “A Medical Education”

This is a blog in which I am planning to collect and curate various writings of mine from 1996 onwards, which in some way relate to medicine or medical practice. “Some way relate” could be very broad. This arises from my inchoate desire to anthologise my writing, and the suggestion (from Simon Cutts and Erica van Horn) that blogging some of my past pieces may be a way to try and find a common thread.

I am a doctor. I have never let this define, or wanted to let this define me. In ways, my writing has always felt like something separate from medicine. I even practice under a different name. A relatively small percentage of what I have written is directly about medicine.

However, medicine is a thread through much of what I have written, even invisible, and all I have written as an adult has been as a medical student or a practising doctor. Some influence, to say the least, is inevitable both ways.

Furthermore, I am interested academically and personally in medical education, and particularly trying to capture the “hidden curriculum”, the processes of becoming that are not captured in any matrix of learning outcomes or assessment schedules. Systems have a life and existence entirely uncaptured by the organogram or the flow sheet.

My initial working hypothesis is to try and gather pieces that will in some way trace my own development within medicine, even tangentially. I intend to publish pieces from the past – some from a few months ago, some from nearly twenty years ago, some from peer reviewed journals, some from student magazines and various freesheets, some written to express a deeply felt perspective, some written for the money (not that many, really) – and see what happens.
Seamus Sweeney

(Jan 15th 2016 – I have some further thoughts about this blog, although I don’t intend to adjust this text)