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In the twenty-sixth episode of the third season of the “Saturdays at Seven” conversation series, Todd Ream talks with Joshua August Daily, Professor of Pediatrics and the Pediatric Cardiology Fellowship Program Director at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital. Daily begins by offering insights concerning how he builds rapport with patients and their family members. That rapport offers Daily with insights into the spiritual commitments held by patients and family members. Daily notes that doing so allows him to serve patients as whole persons and, in turn, be of greater service to them at the intersection of their hopes and fears. Daily then shifts to discussing his own calling to medicine and eventually how that calling came to include pediatric cardiology as well as serving as a physician educator. In addition to the technical competence Daily sought to master through his medical education, he returned to school to earn a graduate degree in education when he discerned he would also serve as a physician educator. Daily acknowledges service as a physician and as a physician educator means long hours that are also spent under stressful conditions. While he is grateful for the ways that the profession has sought to address those challenges, he also fears that many young physicians (especially young physicians who are also evangelical Christians) are avoiding certain specialties in favor of greater work-life relations. While understandable, Daily contends that tendency also leaves those specialties bereft of a Christian perspective. Daily closes by detailing the virtues he believes physician educators need to seek to cultivate in their students, the vices they need to teach their students to confront, and the ways the Church can invest at higher levels in the years to come in the formation of future physicians.
Todd Ream: Welcome to Saturdays at Seven, Christian Scholar’s Review’s conversation series with thought leaders about the academic vocation and the relationship that vocation shares with the Church. My name is Todd Ream. I have the privilege of serving as the publisher for Christian Scholar’s Review and as the host for Saturdays at Seven. I also have the privilege of serving on the faculty and the administration at Indiana Wesleyan University.
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Our guest is Joshua August Daily, Professor of Pediatrics and the Pediatric Cardiology Fellowship Program Director at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital.
Thank you for joining us.
Joshua August Daily: Yeah, Todd, thanks for having me. It’s great to be here today.
Todd Ream: In the eighth and final volume of his Children in Crisis series, the Pulitzer Prize winning psychiatrist Robert Coles, focused on the spiritual lives of children. Long overlooked, Coles believed children’s stories merited our serious consideration, and that doing so would allow us to be of greater service to them.
As a pediatric cardiologist, what habits have you developed when speaking with children?
Joshua August Daily: Great question. So when I engage with children, there is usually multiple layers to that dynamic and that interaction. Not only is the child there, but almost always a parent, potentially grandparents, siblings, sometimes a whole entourage of family members are there. And the context in which those interactions occur may range from the relatively benign, in which it’s a child with a simple heart murmur or chest pain that is unlikely to be the result of real pathology, or those that have major heart issues and are dealing with the potential critical illness and possibly even death of a child. So there’s a wide spectrum and my engagement with the families and the children depend greatly on where they fall within that.
It also depends on the rapport that I’ve had the opportunity to build with them. I had patients that I followed from the time they were, they were fetuses, and then followed them all the way into teenage years or even into adulthood. And then there are those that I’m seeing for the first time. When I’m seeing someone for the first time though, I usually try to engage with the child first long before I start to ask about the reason that they’re here or to deal with the actual chief complaint surrounding the clinic visit.
So that depends on the child’s age, but typically there’s some indicator or something the child’s interested in. So if it’s a 3-year-old and they have Bluey or Bingo, then I immediately start engage with Bluey and Bingo. And I talk about who their favorite character is, and I talk about how I like Bandit. Being the benefit of having four children myself, I have interacted with the vast majority of TV shows, movies, Disney movies, et cetera, that these kids have done. So I usually have more competence in that domain than they anticipate.
So I will spend the first often five minutes engaging in their world, in what they’re interested in. And by then they’re far more comfortable with me, and we can then segue into the reason for the visits. And there’s something about a parent, when you see someone delight and engage in your child, that you become more comfortable. And you naturally trust them more. And whereas in some cases the conversation may just range to, oh, your child’s fine, and then others to their more serious issues, building that trust and rapport on the front end is greatly helpful on the back end.
So I’ll first engage with the child, sometimes play with them. Some kids are very warm and they want to come sit in my lap and I’ll play with them for a little while at the beginning of the visit. I also try to always sit down. It’s very important to me that we have a chair available in every patient room. And there’s even some research that shows when a doctor is seated, a parent’s perception of how much time they spend with them is greater than when the doctor spends the same amount of time but is standing.
So I physically make sure I’m on the same level as them or lower, especially if I have to deliver bad news. I play with the child, I’ll then transition to talking to the parent. Um, and it may be a segue of the child talking about what they talk about, and then we connect as parents and that opens up that rapport with the parent. Or we may just jump into the reason that they’re there today.
And then depending on the nature of that conversation, and what we talk about, I then may kind of wrap things up and that’s the end of it. Or I have patients that I see every six months or every year, and I try to remember details about them. So in my clinic notes, I’ll put the name of their dogs. I’ll put what grade they’re in, what hobbies they like, and I’ll often lead with that when I come in. And I may not have remembered the name of their dog, but I put it in my note and so they feel like I care about them. And there’s this automatic connection when I come in asking them about, you know, whatever the last funny thing their pet has done, or whatever it may be.
Todd Ream: Yeah. So I can imagine even a follow-up visit that you may have, you haven’t seen them for three weeks, four weeks. The first question you come in and say is, “How’s Max doing?” Max potentially being their dog here or something like that? Uh, and then get to the, then get to the more serious details about their lives and, yeah. Not that their relationships with their pets aren’t serious too, to them at least, so.
Joshua August Daily: I just had one of my patients that I followed since the time she was born, and I, at this point, I only see her once a year. And she’s a little girl who’s now almost 10 years old. She came in with a quiz that she had written for me about Disney princesses.
Todd Ream: Oh!
Joshua August Daily: She wanted to see how far my knowledge had progressed in the past year.
And so she had some easy ones and some pretty hard ones. And I did somewhere in the middle in terms of answering the questions for her quiz. So it’s kind of fun to have those longitudinal relationships with kids, and then the connection with the parents really stems through that connection with the child.
Todd Ream: Yeah, I assume the weight of how they understand and anticipate your value to them as a family is heavily invested on the relationship you have with their child and the way you’re able to connect with the child.
In what ways do those stories and those interactions offer you with insights into their spiritual lives?
Joshua August Daily: There are moments in which I brief snapshots into their life and it’s hard to draw too many conclusions based on those. And then there are those where I, longer relationships, and certainly those where we are dealing with a more serious matter. One of the things that I’ve really recognized with children early on in my career, I would envision the things that I would be worried about in terms of the deeper matters of life and death and so forth. And I would try to answer those on the front end or just assume that that’s what their fear or concern, whatever it may be, was. And I have quickly learned that I am often very, very wrong, that the things that kids are actually really struggling with or wrestling with may be very different.
I’ll give you an example of one of those. We had a child that was going to need a heart surgery that was moderately significant heart surgery, at least from my lens. To him, I’m sure was a huge deal. And in my mind, I’m thinking of all the things he’s going to be worried about. And I jump into those and then I ask him what he’s most worried about. And his primary concern is what gaming system was going to be available in his room, in the hospital, whether it was a PlayStation, Nintendo.
And if I had just led with like what his concerns were, like we would, I didn’t even have to go into all these other things that weren’t even on his mind. I gave him extra stuff to worry about and it just amazes me the things that children actually focus on.
And at the end of the day, well, I’m a big believer of engaging with children on a spiritual level. I really think if they know they are loved and delighted in, and that’s evident in every dynamic of our interaction, that their ability to accept God’s absolute love and delight in them is so much greater. And that’s probably the most fundamental way that I can build their spiritual life by just demonstrating that in all of our interactions.
Todd Ream: In terms of working with children and, for example, their, you know, concerns, you know, for example, that may get brokered at times on what gaming device to which they may have access in their room their parents are concerned about different things. Um, so when you’re working with children and parents and perhaps their spiritual lives, you know, in what ways, you know, you found, you balance that you talked about working with the child first, but the parents are still there and, and they have needs also.
Joshua August Daily: Yeah, so I have, I can often, I’m better able to estimate what the parents will be worried about, but I’m still not always on point. And it can differ. It’s not, the dad’s always worried about one thing, the mom’s another, et cetera. There’s a wide range of what they can be worried about. So I always give them time to ask questions.
And there’s a tendency in clinical medicine that you wait till the very end, then you stand up as you’re about to leave the room. You say, hey, any, any last questions? Where the presumption is, they won’t have any. And even how you frame that, you say, what additional questions do you have? So the assumption is that they have additional questions. You remain seated during that, leaned in, using all the nonverbals to communicate. You’re there and present and willing to engage and listen. So there’s even some little things like that that I think I can, I can focus on.
Some of the things that I will often lead with, with a new diagnosis, in particular, often the family is in somewhat a state of shock where they did not see this coming. They’re, they’re not even sure what to be scared of, but they know they’re overcome with fear in that moment. And in those situations, I always provide a little bit of room for silence or for thinking, and then I will often prompt them with some of the questions that other families sitting in your shoes have had or the following. And I will provide some of those and provide answers. And that often gets them thinking and then they start asking additional questions.
And then invariably, while their first questions are focused around the here and the now, what does this mean? When they go home, they tend to think about the future. They think about, will Ellie get to play basketball when she’s older? Or will Johnny get to play football? Will they, will she get to have kids? Will she be having kids of her own? Am I going to be a grandparent? Like, they don’t think about those things on the front end. So I try to somewhat paint that picture.
But I also recognize, depending on the newness of the diagnosis and what is going on. So, for instance, a mother may have just given birth and may be dealing with all the physical trauma of giving birth, or having a C-section, which can invariably influence her understanding of the situation, what she remembers. I recognize that most of what we talk about, they likely won’t remember. So I’m repetitive and I’ll often talk about those same things in the future, offer prompts. I’m willing to answer the same questions again.
But at its core, making sure that I leave space for them to engage in that dynamic. And sometimes that means I schedule clinic visits more frequently than I might have purely for medical decision making but rather for additional connection points with the family to answer questions to prepare them for what’s to come.
Todd Ream: Thank you. In a few minutes, we’re going to talk in greater detail also about your work with future medical practitioners, physicians who are being prepared to serve in roles comparable to yours. So in your estimation then, the kinds of questions that children bring, the kinds of questions their parents bring the way that their lives are ordered, what’s your estimation of the sufficiency of the preparation, the formation for service that healthcare professionals receive? Is there more you think we should be doing? In what ways do you think it’s adequate? Um, yeah, especially when working with children and families of children.
Joshua August Daily: Well, the caveat is with, I recognize the tendency based on the focusing illusion. It is to focus on whatever’s here and now and place increased importance than would you would otherwise place in other situations. So we’re talking about it, so I’m focused on it. So of course the natural response is, yeah, we should do more.
That being said, I also recognize that the amount of information that a physician must learn during four years of medical school and then followed by residency and fellowship, continues to grow at an exponential rate. And there’s always cost and benefits with everything. So the tendency is every specialty, every person that has their thing that they think is important wants to force that into the curriculum, what we’re actually teaching med schools.
And then the next thing you know, something gets bumped out. And so you have, you can’t look at, in isolation, you have to look in totality about what are the most important knowledge, skills, and attitudes for physicians and future physicians to obtain during their medical education. And then how do we most effectively provide those or provide the context in what those can be obtained over the period of four years plus residency and fellowship.
So in medical school, the amount of learning that occurs in that area is very limited. There’s some initial exposure. They may get a lecture. Most of them won’t go into pediatrics though, although they may still interact with children at various times, but there’s a little bit of exposure. Then in residency, which follows medical school, so there’s medical school is four years for all doctors and then there’s residency, a varying links from three to seven years depending the specialty.
Pediatrics is three. Then if you do what I do, pediatric cardiology, that’s another three-year fellowship, plus possibly another one to your two-year fellowship. And so in that residency period, the focus is more on how you connect with kids. And there’s a shift that occurs, whereas medical school there’s a lot of lecture based, formal didactics, similar to what you may see in a college.
Residency is more of an apprenticeship and that you’re providing care alongside mentors and then you see things modeled. So it may not be that it’s explicitly taught as much as it should be, but ideally in the context of clinical care with excellent mentors, it’s modeled on how to connect with these families and connect with the kids and how to engage even in a spiritual domain.
But then that’s highly variable because someone may have a great mentor, someone may have mentors that struggle in that area themselves and don’t have time and so forth. So yes, that’s an area we could do better, but I would want to be very thoughtful, as opposed to just saying, oh, we need a block in medical school focused entirely on this.
I will say that in the spiritual domain the amount of education we receive, especially in secular medicine, is highly lacking. And for a lot of reasons, for political correctness. And for concern about people feeling comfortable, we just basically sidestep that for the most part. So my own practices in terms of how I integrate my faith with my practice of medicine have been learned in large part of my own, or with a few select mentors who may walk with Jesus and our physicians. But there’s been no formal education I’ve received in that area.
Todd Ream: Yep, thank you. I want to transition now to asking you about that education that you received and your calling to serve as a pediatric cardiologist. You earned your MD at the University of Arkansas for health sciences and then did your residency and your fellowship at Cincinnati Children’s Hospital Medical Center.
At one point did you decide practicing medicine was central to your vocation, and what experiences and perhaps mentors guided you along the way?
Joshua August Daily: So there wasn’t a point in time where the clouds opened, the sun’s shone down, and I knew without a doubt, I was meant to be a pediatric cardiologist. You often hear those stories and those stories are often shared in such a way that that’s presented as normative, and I think we do a disservice for the vast majority of us that never have that.
Todd Ream: I’m always jealous of those people myself, actually.
Joshua August Daily: Yeah, I actually suspect that’s not the case and due to their own emotional discomfort, they feel the need to present it in that way, to be sure about who they are. But that aside, that was not my, my story at all. Early on, I enjoyed math and physics and science, but I’ve also thoroughly enjoyed interacting with others. And so there’s a natural progression into medicine with that.
In college, my undergraduate was in physics, which I thoroughly enjoyed. And then I went straight into medical school and there wasn’t one point in time where I decided that it was just always kind of the natural next step. I actually struggled greatly with going between medical school or seminary, which are very different paths. And it’s interesting to think back about the counterfactuals about what my life would’ve looked like had I gone a different path. But I’m so grateful for what I did.
And then as I progressed into medical school, I remember day one, I was convinced I wanted to be an orthopedic surgeon. And looking back on it, it’s kind of funny to think about how I drew that conclusion. Basically, I was an athlete in high school. I liked sports, and I kinda looked like guys who were orthopedic surgeons, at least in my own mind. And so I thought, and they seemed kind of cool, and so I thought that’d be a great vocation for me, which is a terrible way to make that decision. So many people proceed in that path, toward that end.
Then I did cardiovascular kind of physiology early in medical school, and I was naturally drawn toward it as it a lot of what I was inherently good at, I would use in a daily basis in that area. So a lot of math, three-dimensional visualization. I was very comfortable in that space, and I decided with certainty I wanted to be a cardiologist, or at least I articulated that. In part, to manage my own discomfort with uncertainty, which we all have. So it feels far more comfortable to say, this is what I want to do, and just move in that path.
Then I did in my first adult cardiology rotation as a third-year medical student. So the natural path of medical schools, your first two years are primarily formal didactics. You’re in classroom, you learn about anatomy, physiology, et cetera, kinda like college, just a graduate degree in college. Then your third and fourth year are when you engage in clinical rotations. So you may spend eight weeks on surgery, rotating between various surgical subspecialties and various roles, and then rotate between all, at least a core selection of specialties.
So I did internal medicine and some adult cardiology. And I realized in that moment that while I was drawn toward cardiac physiology and pathophysiology, the actual practice of cardiology every day, at least as I saw demonstrated at the time at the VA, which isn’t fully reflective of all of medicine, but I thought it was, that you deal with a lot of the same thing. It’s either coronary artery disease or heart failure, and it tends to be algorithmic. If this, then do this.
And additionally, I was caring for adults, especially elderly adults, in the geriatric range, which need to be cared for, and there will come a day I’m in that range and I hope people kindly care for me. That being said, that wasn’t the most life-giving domain for me to practice.
So I had those experiences, didn’t enjoy it as much. And then I did a pediatric cardiology rotation, and I recognized in spite of, broadly speaking under the umbrella of cardiology, pediatrics differed greatly. So, whereas adults primarily have acquired heart disease, their hearts are structurally normal, but they don’t squeeze as well, et cetera. Children, in the vast majority of cases, have what are called, what’s called congenital heart disease. These are abnormalities. They’re born with holes in the heart, valves that are undeveloped, that are too narrow, that are absent entirely, or chambers of the heart that are absent entirely or plumbing is completely backwards. And so there’s a lot more thinking from a three-dimensional perspective and using the underlying physics and physiology, which is what I enjoyed so much.
In addition, I love taking care of kids. Not only are these interactions life giving, but the opportunity for impact is different. When you care for a child and you do a good job and they live a full and normal life, that’s very different than caring for someone in their eighties, who you may get a few extra years.
And even within that, most adult cardiology is a function, at least in part of lifestyle. And so you can do a great job caring for them, but if they don’t change their lifestyle, the actual outcome may not change. Whereas kids, they had nothing to do with their disease. It is so much easier to be gracious for a child that is in that situation and had nothing to do with it themselves.
In addition, there’s something about the sickness and possible death of an infant or child that’s just different. It impacts a family in a fundamentally different way. When it’s grandma or grandpa, there’s a component of that that’s expected. That is the way of life, and there’s sadness, yes, but they lived a good life. This is what happens. When it’s a child, it should not be that way, and we know that at our core. And so to step into that situation and walk with a family through that space, while not emotionally comfortable, there’s something sacred about it and deeply meaningful. And I feel so grateful that I get to do that on a regular basis.
So that’s my kind of long-winded answer to how I got where I got through the various paths of training and when I decided to become a pediatric cardiologist.
Todd Ream: Yeah, thank you. Without violating patient confidentiality, would you mind sharing a story of a challenge you faced as a pediatric cardiologist that not only proved challenging but also vocationally satisfying, where you were able to meet the needs of a child in the ways that you were sort of talking about and strike at the core of your vocation?
Joshua August Daily: I have a number of stories that I could draw from. And I, I’ll share just one briefly. There was a baby born with a major congenital heart disease that was possibly incompatible with life and had some other issues as well, and a family that was deeply struggling with not only is it the loss of a child, but it’s the loss of hopes and dreams, of what you anticipated, what you expected. And it’s so abrupt, especially when there’s not a prenatal diagnosis.
So sometimes we make the diagnosis before the mom gives birth, and they have a while to prepare for it. Other times they give birth, and suddenly it’s this new diagnosis that changes the entire trajectory of the child’s life. And this is one of those scenarios. And this family was holding onto hope that, okay, so there’s an issue with the heart, well, we can fix it and move on. And over the first few weeks of life it became very apparent that would not happen, that this infant would die. And the family was struggling with coming to grips with that and how to navigate that and they ended up being a family of faith.
One of the practices I employ as part of just my regular everyday is when I interact with a family and give a new significant diagnosis, or we decide to send their child to heart surgery or a major catheterization procedure, I offer to pray in those situations. So I had offered to pray for this family very early at the very first time, and then they’d asked me to pray every time we talked. That opened a door to engage with them in a way that the other doctors couldn’t, other nurses couldn’t.
And we ended up praying through, in almost a liturgical way of life, acceptance, death, what this means for the future, the hope of a new heaven and a new earth. And we arrived as a decision to redirect care and there was tremendous sadness wrapped up in all of that. But there was also something deeply meaningful—to get to engage with them and care for them at their time of greatest need.
Most people don’t get to interact with people regularly in that space. And I do. And I just, that is a tremendous gift and it takes it a toll. And as a physician, I have to be careful. I think there’s two extremes, both unhealthy. There’s a tendency to be somewhat robotic and divorce yourself from emotional processing and just think of it from an entirely analytical perspective. And those things take a toll, and if you don’t process them, engage with them, then they’ll manifest in a variety of ways that don’t make sense in your own life.
But then the other end of the extreme is to identify with every patient and allow myself to be swept up in the motion of that moment. And when I’m running a code, I can’t be thinking of what the family’s feeling. I have to be thinking about when do we give epinephrine? Who’s doing compressions? I need to be divorced from that. I need to completely compartmentalize and set that away.
And so there’s this way in which you live life, I need to live life where I can compartmentalize it for a time, but then I reengage with it. And I allow myself to allow it to wash over me, to acknowledge the various emotions I’m feeling to release them to God. It’s hard to do, but allows for a rhythm of life that ultimately draws me closer to Jesus as I recognize that my life will come to an end. We will all be there one day. And the reality that our hope is not in medicine, but it is in the return of Jesus, the new heaven and new earth. And it allows me to be reminded of that in a way that a lot of people in our vocations don’t get to. And so I’m, I feel so blessed that I get to do that.
Todd Ream: Yeah, thank you. In terms of that rhythm that you experience there, is there a way which you could describe and allow us to walk alongside you during a typical day? Or is there even a typical day in terms of what you experience and sort of what are the challenges and opportunities that sort of punctuate that day?
Joshua August Daily: So different pediatric cardiologists may have different subspecialties and their days may look very different. But mine, I will, I wear a number of hats, so I am, I do a lot of, I have a lot of clinical responsibilities. I do a lot of other things too. So I have clinic one day a week, which most people can comprehend. I see patients in clinic, we get ultrasounds that are hard. I talk to them. That’s probably the easiest to envision. I also spend a day or two in our echocardiography laboratory, which basically means I interpret ultrasound images of the heart. I may go in and perform some of those myself.
And then I’m also, as part of that in the operating room, I perform what are called transesophageal echocardiograms, which are basically ultrasounds of the heart you do through the esophagus while the surgeon is doing surgery. So it’s interactive or making decisions based on exactly what we’re seeing there. So I do a lot of those as well.
And then I may have various weeks where I’m on service, where I’m the cardiologist in charge of taking care of all the patients admitted to the hospital with heart issues, and that’s entirely focused on that. And I may have like six weeks where I do that all week throughout the year.
I’m also the fellowship program director, so I’m in charge of training all of the pediatricians who are becoming pediatric cardiologists as part of our program. So I meet with them, I oversee their clinical rotations, I provide direct teaching. I also teach a course for fourth-year medical students on finances. And so I give lectures in that area and financial model within medicine.
And then I mentor a lot of trainees everywhere from m-ones being a first-year medical student through residents and fellows, and then junior, mid-level attending physicians like myself. I do a lot of that as well. So my day varies a lot from one day to the next, but most pediatric cardiologists are primarily clinical, about half of what I do is clinical, half is other stuff.
Todd Ream: At what point in time did you decide then you also wanted to embrace these responsibilities as a physician educator and work with the next generation?
Joshua August Daily: So it’s similar to my story becoming a pediatric cardiologist. There wasn’t one point in time. It was in an iterative fashion that I’ve slowly developed as part of my life. Early on, I recognized I enjoy teaching and I seem to thrive in those environments. So toward the end of my fellowship, I decided to pursue formal training in education.
In medicine, the vast majority of physicians have no formal training in how to teach effectively, and they simply taught in the way they were taught, which tends to be lectures given by PowerPoint and possibly embarrass heated questions that are somewhat embarrassing to put people on the spot. There’s this whole culture within medicine with how we engage and what’s accepted, and so.
All that to say, I went out and got my master’s in education and I did that while I was working during my first few years of faculty, really to get the knowledge and skills to be a more effective teacher. But additionally, one of the things I recognized is simply having the letters after my name, people assumed I was an expert in it. So I got all sorts of doors open to me, that it wouldn’t have otherwise been opened.
You know, at the time, I was the only physician in my medical system that had a master’s in education. So in the land of the blind, the one eye man is king. So everyone assumed I was the education expert. Even I didn’t know much more. So a lot of doors were open to be very early on. And it started, I became the associate fellowship program director right away. Thoroughly enjoyed that, relatively quickly extended to become the fellowship program director. Enjoyed that. Felt like I was effective at it.
Started giving some lectures on finances, which was kind of a hobby of mine, something I did on the side, got a lot of good feedback. Most doctors know nothing about money and don’t get any formal training in that. So then that expanded a lecture series, and then eventually a whole med school course. And now I write, I’m a financial columnist as well. I write in that space on the side as well. So that area has continued to grow just a little, a little at a time.
And then more recently, even in the last few years, I’ve become very interested in the way we make decisions, in particular, that physicians make decisions in two domains within the regard to patient care and the way that we’re predictably irrational, yet we think we’re making high quality decisions there. And then as we make decisions about our lives, what specialty to choose, where to get a job, how to construct our lives. And so I’ve become far more interested in that area recently and do a lot of writing and speaking in that area. And who knows, another five or ten years or maybe something else that I’m deeply interested in, I focus more of my time.
But it is interesting to look back. If I looked at my 25-year-old version of myself, I would not have anticipated that these would be the things that I would spend the bulk of my time doing or have the greatest interest in. And. I think there’s some lesson in that, especially in medicine. Because unlike so many other vocations, we make decisions with really long training paths that have trajectories with very little ability to change course further down the road.
So let’s say that someone trains to be a pediatric cardiologist, and then I decide actually I want to be a congenital heart surgeon. I’d have to go back and train another 10 years and make very little money and move my family across the country, and there’s no way I could do that. So once I’ve decided to do this, I’m kind of stuck in the specialty for the most part.
And so, but people, physicians make those decisions typically in their mid to late twenties. And often they have difficulty anticipating what will be important to them 10, 20 years down the road. And they assume that their present selves, their interests, their focus, their priorities will remain unchanged in the future. And so then they make these decisions that then lead to ultimately, sets them up for burnout or a job they don’t enjoy or any variety of things down the road. So I even see that in my own life, and I think there’s God’s grace interwoven through throughout it, as I thoroughly enjoy my job, and I think it’s a great fit for me, in spite of the fact that the way I made those decisions early on wasn’t in the highest quality.
Todd Ream: Thank you. For individuals then discerning a call to medicine or also, you know, on top of that, a call to pediatrics then, what advice would you offer, especially if they’re making decisions in their late twenties, mid to late twenties, early thirties, that are going to have ramifications for them, you know, possibly for decades to come.
Joshua August Daily: Well, first, I’d step back briefly and talk about what a calling is because I think there’s a lot of confusion about what that may mean, especially among Christians and evangelical Christians in particular. And so early in my life I thought that maybe that meant either there’s one thing I was meant to do is if there’s this blueprint for my life that God had orchestrated all this ahead of time and I was meant to be a pediatric cardiologist, and I better discern that path. And if not, my life was not going to be aligned with His will and that I would be way off course.
I think when you step back and talk about just God’s will and that from that lens, it’s helpful to have kind of the three different categories of God’s will that are laid out by like Friesen and Kevin DeYoung. This idea that there’s God’s sovereign will, what He has determined will happen and there’s nothing I can do about it, that Jesus will return and make all things new. That’s very clear cut. There’s God’s moral will. The will that He has made very clear is revealed through Scripture about how we live our life. That’s our sanctification, that we love others and love God. And then there’s the will of wisdom where we have the freedom to choose. And within those confines, there’s multiple reasonable options. There may be one option better than another, and I fully think most vocational decisions fall in that third category.
Now, there are some vocations that are against God’s will. I should not be a drug dealer. That’s very clear cut. But the choice of becoming a physician or a pastor, or a pediatric cardiologist or a neurosurgeon, I think I could have lived a good life within each of those paths, honored God, glorified Him, become more sanctified, love Him, and loved others. And so in so much as God’s calling indicated a clear blueprint in one choice for my life, that never occurred.
However, in so much as you view, calling from the lens of something you’re intrinsically motivated to do. It’s about others, this deeply meaningful work. I feel like my life is very, very, very much a calling. And so even in talking about, it’s interesting in medicine right now, if you look at the vocation of medicine, from the perspective of job, career, calling, and these three different ways of thinking about it, there’s been a huge shift. And even within myself, so historically, most physicians viewed medicine as a calling—this thing that was, they’re intrinsically motivated to do that was about their patients. And because of that, they were willing to make tremendous sacrifices.
There were time periods where residents actually lived in the hospital. They didn’t even live at home with their families. And there were long, long periods of time, which doctors would work 80 hours a week. Their life was medicine and being in the hospital. And then there was, there’s been a shift in the last 20 years, away from that for very understandable and good reasons, where we’ve recognized the costs of that level of sacrifice in many cases are too great. Burnout is extremely high. Huge impact on marriage, divorce, your role as a parent, your role as a friend, your role in the Church, et cetera.
And so there’s been a shift more toward viewing medicine, either as a job, which is primarily transactional. I have this skill, I do this, I get paid. Um, what you may think of your first, first job when you turn 16 or a career where you have this trajectory, but you’re not that intrinsically motivated in what you do, doesn’t feel deeply meaningful, but it’s something that you can continue to earn more money in and work towards.
And so there’s a lot of physicians now, especially newer physicians, that value work-life balance life, outside the hospital, and have moved a little bit more toward that career or even job perspective. And I think there are downsides with each of those, and I see that in my own life. If you’re a calling doctor and fully embrace that, hospital administrators take advantage of you. They will say, hey, for these kids, you better take the call. They, they, we don’t have anyone to take it. You got to take it. And so your family suffers. And so you have to be real careful about that. But if you have a job or even career perspective, we’re missing out on so much of what I think God has in store for us and the opportunity to deeply engage and recognize the meaning of what we do.
I very much fall within the calling perspective. I really am intrinsically motivated when I do, and I feel like it’s deeply meaningful. But I also try to step back and recognize the practicalities around and the trade-offs surrounding that, and be very intentional and thoughtful and set up boundaries around that part of my life. And as I’m teaching medical students, residents, fellows about those decisions, I try to present all of those lenses.
And we talk about, for instance, money. For a long time, doctors did not talk about money. It’s like you do what you’re supposed to do because you’re called toward it, and then as a result, you may get taken advantage of, not paid as much as your skills are worth, et cetera. There’s all these downstream effects. So we actually bring that data into that discussion and talk about the role that should actually play in decision making and how you should think about things through those three lenses.
And I’m continuing to wrestle with that in my own life. It’s not as simple as you fully embrace one and not the others, but you need to think about it through all of those lenses.
Todd Ream: Thank you. That’s very helpful. As our time begins to become short, I want to ask you as a physician educator then, and as this shift, you know, has been taking place within the profession that you just described, what virtues, intellectual and moral virtues have you found are important to cultivate in the next generation of physicians whether they be, you know, pediatricians, pediatric cardiologists, et cetera?
Joshua August Daily: Well, I think that’s a difficult question to ask, in that I could quickly spout off the typical virtues that most, the most would say. And yeah, they all make sense and they’re all important. Love I think is central to what we do. And I mean, Scripture makes that very clear for every believer, but in particular in what we do.
And so then there’s the matter of how you cultivate education that starts in the homes that they grew up in, the relationships with God that they cultivate, or even those that aren’t believers. How we cultivate that in them, because most of the trainees that I train are not Christians or they may be cultural Christians, but that’s not a significant part of their life. And so how do you even cultivate those types of virtues in someone that doesn’t follow Jesus? That’s a separate issue that has layers to it as well.
I think all of them all love and integrity I would put as the top, top two in terms of the things that I would prioritize the most. But you could make an argument for any of them. And I don’t have a ton of great ideas as a medical educator at my stage in the game on how to cultivate those other than in so much, to clearly demonstrate them in what I do and then to engage with trainees in a way that’s both, that’s loving but not always kind. So that don’t just tell them they’re great, to call them out, to show them where they need to grow, show where there’s hypocrisy, that they did whatever it may be in a way that wasn’t consistent with the virtues that they would articulate or important in their own life, are engage in those hard conversations early on.
And I have the opportunity to do that as a program director and a mentor in a way that others may not at different points in their life. So for instance, if I have a colleague, who’s let’s say 45, and he’s working next to me and he’s doing some stuff that’s just questionable ethically, my ability to engage with him and have an open door is somewhat limited. And it depends on my relationship with him. If I’m his boss, obviously I’m supposed to do more. I have more of an open door, but as a colleague I don’t.
But as a fellowship program director with trainees that are directly under my supervision in a somewhat hierarchical system, I have a little bit more opportunity to engage with them in that way. And there’s this window. So I want to take advantage of it, in so much as helping form them into the kind of doctors that will care for the patients who trusted them over a lifetime with compassion and love, and do the best job I can during the season, recognizing the season comes to an end when they’re done with fellowship.
Todd Ream: Thank you. For our last question then today, I want to ask about the relationship that the Church shares also with the formation of physicians, especially those who profess faith in Christ, because at one time, the Church was the largest provider of healthcare, arguably. In the years to come though, in what ways do you believe the Church can be of greater service to physicians and perhaps to pediatricians and future pediatricians?
Joshua August Daily: Well that, we could have an entire podcast just talking about the relationship of the Church in medicine. And so instead of trying to broadly answer that within healthcare as a whole, which there’s a lot of ways, I’ll talk in particular about the training of physicians because that’s where I have a little more expertise and spend a lot of my time. And I have, I have seen a trend, which is anecdotal, I recognize. There’s not great data surrounding this, but in terms of the types of medical students and doctors that we train, and those that are people of faith, and the decisions they make and what they choose.
And there is a sense in which I think the pendulum has swung too far among the Church of valuing work-life balance, prioritizing time outside the hospital, and not recognizing the sacred calling, sacred calling that is in medicine and not, not being willing to take those, make those sacrifices.
And I’ll just, this is my anecdote, but there is a, I train a lot of physicians who come from very different places, in particular a lot of international medical grads, a lot from the Muslim world. And when someone has to work a 30-hour shift, you have to stay late and there’s a patient crumping, a patient approaching death, there is a time to stay late and to set things aside. And there is a tendency, I think, of some laziness among Christians and some unwillingness to make those sacrifices. That is my anecdotal sense.
And so in particular, those of the, the Muslim face seem to do a better job of that right now, in terms of trainees, recognizing the anticipation/expectation of their judgment before Allah and what that will mean and that everything will be held in the balance greatly influences what they do in a way that us as believers do not, or at least from what I’ve seen. So I have seen a trend away from the more demanding specialties and a trend toward the more lifestyle specialties among evangelical Christians who are entering medicine.
And I can, well, I can understand a lot of that. And I don’t think every Christian has to choose the most difficult thing. I do think that’s somewhat of a shame, that we have as a Church, we have a long history of pursuing various domains in academia with excellence, in being the absolute leaders. In my field, now, that is not the case, that you look at those that are doing the greatest work right now and they’re not believers.
And I could tell you some stories about experts and advancements that have been made, but we are not in the forefront of that as we have been, I think, at other times in the past. And I think that starts in our homes, in the way we raise our children, and the Church, Church and a college. And that the value of hard work, of adopting a craftsman mentality, where you should become absolutely excellent at whatever God has led you to do and the ways in which that can expand your influence and ultimately expand his kingdom and glorify God.
I think the pendulum has swung a little too far in the wrong direction, broadly speaking, with regard to the Christians entering the field of medicine and training to be physicians. And that’s my own anecdote and that may be related to where I live in part and my specialty, but that’s been my sense.
Todd Ream: Thank you very much. Our guest has been Joshua August Daily, Professor of Pediatrics and the Pediatric Cardiology Fellowship Program Director at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital. Thank you for taking the time to share your insights and wisdom with us.
Joshua August Daily: Thank you, Todd. It’s been great, great being here today. I thoroughly enjoyed it.
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Todd Ream: Thank you for joining us for Saturdays at Seven, Christian Scholar’s Review’s conversation series with thought leaders about the academic vocation and the relationship that vocation shares with the Church. We invite you to join us again next week for Saturdays at Seven.
