The medical student or the optimist: the best of all possible chocolate biscuits and how suffering in healthcare became normal

What’s the worst thing you’ve ever experienced as a doctor? Has anything in the world of healthcare come as a total shock? Do you question if things could be made better or does everything happen for a reason as part of some divine masterplan? Candide: or, The Optimist is a satirical work written by Voltaire and first published in 1759. It follows the story of Candide, a naive young man, coming of age through a series of events that transform his view of the world. His journey has been compared to the journey that medical students take, beginning as impressionable and idealised undergraduates through to skeptical and realistic doctors. Obviously the story of Candide doesn’t exactly mirror one of modern medical maturity, but I would argue that there are some thematic threads which can be extrapolated and reflected upon by those working in the medical profession.

SPOILER ALERT: This post will be going through some sections of the story and stopping off at a number of different points to reflect on how the Candide’s experiences might relate to your own. I’ll also be using the excellent illustrations for Candide by Jean-Michel Moreau. So, if you don’t want to know what happens (or even if you do) then consider if you want to scroll down. Whatever choice you make, it must necessarily be for the best. After all, we live in the best of all possible worlds, don’t we?

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Learning objectives

1. Understand the the philosophical position of optimism and the term ‘the best of all possible worlds’

2. Consider how Leibniz optimism might cloud your view of healthcare provision

3. Reflect on your role within a complex system and your ability to change it

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To better understand Candide, I think it’s important to first define what we mean by optimism. The common use of the term today is being hopeful and confident about the future or believing that something will work out. However, at the time Voltaire wrote Candide it was used to describe the philosophical doctrine that that world in which we live is the best of all possible worlds. In spite of all the horrors that we might experience or know of (natural disasters, war, social injustice etc.), this world must be the best since God could not have it any other way. Therefore, everything that happens must be (eventually) for the overall good.

Not an original Moreau

Gottfried Wilhelm Leibniz wasn’t the inventor of the delicious ‘more chocolate than a biscuit’ biscuit but was a philosopher who first coined the term ‘the best of all possible worlds’. He tried to help solve the problem of evil or how we can reconcile why an omnibenevolent, omnipotent and omniscient God could allow suffering and injustice. Leibniz optimism interprets bad things that happen to be not only unavoidable but also necessary for this best of all possible worlds. Indeed, he claimed that ‘an evil brings forth a good’ and that ‘the shadows bring out the colours’. Or, on a more confectionery note, although we got syphilis from the New World we did also get chocolate as part of the bargain. Voltaire mocks this philosophical position in Candide.

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Candide being told he has spent too much time in the medical school library but not enough time on the medical wards

 

At the start of the work, Candide is being indoctrinated with Leibniz optimism by his mentor Pangloss, who he believes to be the greatest philosopher in the world:

‘It is demonstrable,’ he [Pangloss] would say, ‘that things cannot be other than as they are: for, since everything is made to serve an end, everything is necessarily for the best of ends. Observe how noses were formed to support spectacles, therefore we have spectacles.

Candide is soon kicked out of his comfortable castle and a comparison might be made with how medical students leave home for medical school, how medical students transition from preclinical to clinical education or how students graduate as junior doctors.

Questions

Do you remember your first lecture at medical school and how impressionable you felt?

Did you (or do you) have a mentor or someone who you looked upto or perhaps idolised?

How ready did you feel upon entering the hospital wards for the first time?

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Candide trying to escape the task of medical clerking in his local A&E department on a normal Saturday night

 

After being coerced into military service, Candide witnesses the horrors of war and decides to flee to a neighbouring village. Here he encounters a (now) syphilitic Pangloss telling him how his previous castle home has been destroyed with Cunégonde (Candide’s love interest) violently raped and subsequently disembowelled.

Military metaphors are commonplace in medicine: battle with cancer, fight against disease, doctor’s orders. A&E or emergency departments war zones and war on cancer. The metaphor may become distorted; working in challenging circumstances using such military terminology may itself change the way you view your world. A week of impending night shifts may indeed become a battle against physical and mental fatigue.

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Questions

Have you ever tried to avoid particular medical departments, hospital wards or colleagues?

Have you ever seen your mentors in a different light?

Are some battles in medicine impossible to win?

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Candide always remembers to examine from the patient’s right side

 

Candide is later reunited with and surprised to learn that Cunégonde is still alive:

So were you not raped after all? And were you not disembowelled, as Pangloss the philosopher assured me was the case?’ – ‘I most certainly was, in both cases,’ said the lovely Cunégonde, ‘but these things are not always fatal… A person of honour may be raped once, but her virtue emerges all the stronger for it.’

Nietzsche famously wrote ‘What does not kill me makes me stronger.’

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Questions

Is this adage true for healthcare staff?

Do we feel better about ourselves or more virtuous if we make it through a particularly difficult on-call/work shift?

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Candide’s cannulation technique leaves a lot to be desired

 

It turns out that Cunégonde had been rescued but subsequently sold to a merchant. The merchant is furious when he discovers Cunégonde and Candide together. He attacks who he believes is an unarmed Candide, who however has a sword and kills the merchant. Cunégonde is horrified:

‘Holy Mother!’ she cried. ‘What will become of us? A man killed in my house?

Candide then already embarked on killing feels he has no choice but to kill a second man who discovers them:

‘There goes another one,’ said Cunégonde.

Healthcare staff have a unique perspective on life and death. Perhaps it is easy for some healthcare professionals to forget how things which once may have horrified them have been normalised. The more often horrible things happen, the more normal they become.

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Questions

Are certain errors not only unavoidable but necessary for learning?

Should hospitals viewed as places of health or disease?

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Candide starts his module in general practice/family medicine

 

On his travels, Candide encounters a slave and asks him why he is in such a deplorable state:

When we work in the sugar-mills and get a finger caught in the machinery, they cut off the hand; but if we try to run away, they cut off a leg: I have found myself in both situations. It is the price we pay for the sugar you eat in Europe… I am no genealogist; but if these preachers are telling the truth, then we are all second cousins. In which case you must admit that no one could treat his relatives more horribly than this.’

Doctors can become factional. I’ve previously touched on some of the divides (real or artificial) within healthcare systems that keep doctors separated and ignorant of the circumstances of the other.

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Questions

Are doctors in any particular branch of medicine more important than others?

Do some areas of medicine protect/filter/subsidise others?

Should all doctors be paid the same regardless of specialism?

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Candide returns back to Europe and accidently encounters Paquette, a previous acquaintance from home. She initially appears very happy and Candide is therefore surprised when she recounts her misfortunes which have eventually led her into prostitution:

‘But you looked so gay, so happy, when I ran into you just now,’ said Candide to Paquette; ‘you were singing, you were caressing your monk so naturally and affectionately; you seemed to be as happy as you now claim to be miserable.’ – ‘Ah! Monsieur,’ replied Paquette, ‘that is another of the miseries of our profession. Yesterday I was beaten and robbed by an officer of the law; today I must seem in good humour to please a monk.’

Now, before you ask, I’m not equating prostitution with medicine. However, Paquette does discuss how in her profession she has to appear happy (to attract custom). Indeed, it has been suggested that doctors should behave more cheerfully to avoid a mistrustful toxic environment to improve patient outcomes.

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Questions

Should patients know if their doctor is working within a toxic environment (whatever that really means)?

Can you maintain a facade of positivity if you are persistently exposed to negativity?

Are you more Panglossian than you thought?

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Following his experiences Candide increases considers his views about the world and all the suffering people endure. Toward the end of the work, he consults a celebrated dervish and asks:

‘Master, we have come to beg you to tell us why so curious a creature as man was ever created.’ – ‘And what has it to do with you?’ answered the dervish. ‘Is it any business of yours?’ – ‘But surely, Reverend Father,’ said Candide, ‘there is a dreadful amount of evil in the world.’ – ‘And what does it matter,’ said the dervish, ‘if there is evil or if there is good? When His Highness the Sultan sends a ship to Egypt, does he worry whether the mice on board are comfortable or not?’ – ‘So what must we do?’ said Pangloss. – ‘Keep your mouth shut,’ said the dervish. – ‘I flattered myself,’ said Pangloss, ‘that you and I might have a little discussion about effects and causes, about the best of possible worlds, the origin of evil, the nature of the soul, pre-established harmony …’– At which the dervish slammed the door in their faces.

Candide and his companions eventually retreat to a small farm where and reflects on what the dervish has said. The work famously ends with Pangloss telling Candide that everything really did turn out for the best and the response being:

‘All I know,’ said Candide, ‘is that we must cultivate our garden.’

This final remark remains open to interpretation.

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So what can doctors learn from Candide? I assume that most people reading this don’t believe that God has created the best of all healthcare systems. I do however suspect that many doctors believe that they are working within a system in which they wield no significant influence over. The overseer is anonymous often behind multiple layers of bureaucracy. The system may be one that is inherited, a legacy project blanketed with Byzantine complexity to the point of unintelligibility. When something horrible does happen it is simultaneously easy to accept but hard to explain.

In an attempt to understand the sometimes horrible world in which he live, we may either try to attribute blame to an individual (or a few individuals) or alternatively direct our thoughts to some vague system failure seemingly beyond rational control, a Panglossian acceptance of the world and the way things are (or have to be): doctors have to work silly hours to get decent training, if you’re not exhausted to the point of tears then you haven’t been working very hard, if you can’t manage training and a family and whatever else life throws at you then you must be weak or a failure undeserving of investment.

Are we really that surprised then when mistakes and other horrible things happen in healthcare? Not really? Of particular concern is how some might try and rationalise these mistakes with the superhuman demands they place on themselves. They might genuinely believe the mistakes are an inevitable and necessary part of the system that brought them to where they now are: healthcare optimism.

This type of thinking is manifest in the findings of a number of inquiries, perhaps none more than the Mid Staffordshire NHS Foundation Trust Public Inquiry:

“…an engrained culture of tolerance of poor standards, a focus on finance and targets, denial of concerns, and an isolation from practice elsewhere… It took false assurance from good news, and yet tolerated or sought to explain away bad news… There was a combination of factors, of deficiencies throughout the complexity that is the NHS, which produced the vacuum in which the running of the Trust was allowed to deteriorate.”

The events that Candide experiences on his journey force him to reflect on his beliefs and, despite the attempts of normalising evil as part of some divine system, he has the insight to know that this cannot be the best of all possible worlds. Robert Francis writes that “trainees are invaluable eyes and ears in a hospital setting” and indeed our so-called naive juniors may hold the key in allowing us to reflect on how our own nature may have been altered by experience.

The concluding ‘cultivate our garden’ remark may be interpreted in a number of ways. Perhaps it means not to concern oneself with external affairs; an attitude of concerning yourself with only your own practise and patients while avoiding the wider healthcare system. Or is the ‘cultivate our garden’ conclusion as stupid and ridiculous as trying to understand life itself? Don’t fret trying to solve unsolvable problems or answer unanswerable questions. Try not to let irrationality of illness and disease upset you, that’s just the way things are. Perhaps the garden represents your own life and cultivating it means taking charge of your own actions and destiny.

Please add your own thoughts in the comments section below.

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Summary

Optimism is the insistence that all is the best it can possibly be despite evidence to the contrary. Doctors repeatedly exposed to horrible events may unintentionally normalise them as a means of rationalising their healthcare system and their place in it. When medical students start their journey in healthcare, they might be indoctrinated by mentors who may lack insight. Students may find themselves trying to reconcile their survival in a competitive, complex, irrational and unfair system which they feel powerless to change. Asking an 18 year old why they want to become a doctor is facile, but asking them why they wouldn’t want to become a doctor is a much more important question.

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Further resources

Voltaire, Francois. Candide, or Optimism (Penguin Classics). Penguin Books Ltd. Kindle Edition.