Monthly Archives: June 2012

“Doctor’s Office . . .”

Looking for a new primary care physician some time back, I received a referral from one of my specialists and called the office.  “Doctor’s Office . . .”   Thus began my nonconversation with the office receptionist.  We never progressed beyond the generic opening, as the receptionist was inarticulate, insensitive, unable to answer basic questions in a direct, professional manner, and dismally unable, after repeated attempts, to pronounce my three-syllable name.  When I asked directly whether the doctor was accepting new patients, the receptionist groped for a reply, which eventually took the form of “well, yes, sometimes, under certain circumstances, it all depends, but it would be a long time before you could see her.”  When I suggested that the first order of business was to determine whether or not the practice accepted my health insurance, the receptionist, audibly discomfited, replied that someone else would have to call me back to discuss insurance.

After the receptionist mangled my name four times trying to take down a message for another staff member, with blood pressure rising and anger management kicking in, I decided I had had enough.  I injected through her Darwinian approach to name pronunciation – keep trying variants until one of them elicits the adaptive “that’s it!” — that I wanted no part of a practice that made her the point of patient contact and hung up.

Now a brief  letter from a former patient to my father, William Stepansky, at the time of his retirement in 1990 after 40 years of family medicine:  “One only has to sit in the waiting area for a short while to see the care and respect shown to each and every patient by yourself and your staff.”  And this from another former patient on the occasion of his 80th birthday in 2002:

“I heard that you are celebrating a special birthday – your 80th.  I wanted to send a note to a very special person to wish you a happy birthday and hope that this finds you and Mrs. Stepansky in good health.  We continue to see your son, David, as our primary doctor and are so glad that we stayed with him.  He is as nice as you are.  I’m sure you know that the entire practice changed.  I have to admit that I really miss the days of you in your other office with Shirley [the receptionist] and Connie [the nurse].  I have fond memories of bringing the children in and knowing that they were getting great care and attention.”[1]

Here in microcosm is one aspect of the devolution of American primary care over the past half century.  Between my own upset and the nostalgia of my father’s former patient, there is the burgeoning of practice management, which is simply a euphemism for the commercialization of medicine.  There is a small literature on the division of labor that follows commercialization, including articles on the role of new-style, techno-savvy office managers with business backgrounds.  But there is nothing on the role of phone receptionists save two articles concerned with practice efficiency:  one provides the reader with seven “never-fail strategies” for saving time and avoiding phone tag; the other enjoins receptionists to enforce “practice rules” in managing patient demand for appointments.[2]  Neither has anything to do, even tangentially, with the psychological role of the receptionist as the modulator of stress and gateway to the practice.

To be sure, the phone receptionist is low man or woman on the staff totem pole.  But these people have presumably been trained to do a job.  My earlier experience left me befuddled both about what they are trained to do and, equally important, how they are trained to be.  If a receptionist cannot tell a prospective patient courteously and professionally (a) whether or not the practice is accepting new patients; (b) whether or not the practice accepts specific insurance plans; and (c) whether or not the doctor grants appointments to  prospective patients who wish to introduce themselves, then what exactly are they being trained to do?

There should be a literature on the interpersonal and tension-regulatory aspects of receptionist phone talk.  Let me initiate it here.  People – especially prospective patients unknown to staff – typically call the doctor with some degree of stress, even trepidation.  It is important to reassure the prospective patient that the doctor(s) is a competent and caring provider who has surrounded him- or herself with adjunct staff who share his or her values and welcome patient queries.  There is a world of connotative difference between answering the phone with “Doctor’s office,” “Doctor Jones’s office,” “Doctor Jones’s office; Marge speaking,” and “Good morning, Doctor Jones’s office; Marge speaking.”  The differences concern the attitudinal and affective signals that are embedded in all interpersonal transactions, even a simple phone query.  Each of the aforementioned options has a different interpersonal valence; each, to borrow the terminology of J. L. Austin, the author of speech act theory, has its own perlocutionary effect.  Each, that is, makes the recipient of the utterance think and feel and possibly act a certain way apart from the dry content of the communication.[3]

“Doctor’s office” is generic, impersonal, and blatantly commercial; it suggests that the doctor is simply a member of a class of faceless providers whose services comfortably nestle within a business model.   “Doctor Jones’s office” at least personalizes the business setting to the extent of identifying a particular doctor who provides the services.  Whether she is warm and caring, whether she likes her work, and whether she is happy (or simply willing) to meet and take on new patients – these things remain to be determined.  But at least the prospective patient’s intent of seeing one particular doctor (or becoming part of one particular practice) and not merely a recipient of generic doctoring services is acknowledged.

“Doctor Jones’s office; Marge speaking” is a much more humanizing variant.  The prospective patient not only receives confirmation that he has sought out one particular doctor (or practice), but also feels that his reaching out has elicited a human response, that his query has landed him in a human community of providers.  It is not only that Dr. Jones is one doctor among many, but also that she has among her employees a person comfortable enough in her role to identify herself by name and thereby invite the caller to so identify her – even if he is unknown to her and to the doctor.  The two simple words “Marge speaking” establish a bond, which may or may not outlast the initial communication.  But for the duration of the phone transaction, at least, “Marge speaking” holds out the promise of what Mary Ainsworth and the legions of attachment researchers who followed her term a “secure attachment.”[4] Prefacing the communication with “Good morning” or “Good afternoon” amplifies the personal connection through simple conviviality, the notion that this receptionist may be a friendly person standing in for a genuinely friendly provider.

Of course, even “Good morning, Marge speaking” is a promissory note; it rewards the prospective patient for taking the first step and encourages him to take a second, which may or may not prove satisfactory. If “Marge” cannot answer reasonable questions (“Is the doctor a board-certified internist”  “Is the doctor taking new patients?”) in a courteous, professional manner, the promissory note may come to naught.  On the other hand, the more knowledgeable and/or friendly Marge is, the greater the invitation to a preliminary attachment.

Doctors are always free to strengthen the invitation personally, though few have the time or inclination to do so.  My internist brother, David Stepansky, told me that when his group practice consolidated offices and replaced the familiar staff that had worked with our father for many years, patient unhappiness at losing the comfortable familiarity of well-liked receptionists was keen and spurred him to action.   He prevailed on the office manager to add his personal voicemail to the list of phone options offered to patients who called the practice.  Patients unhappy with the new system and personnel could hear his voice and then leave a message that he himself would listen to.  Despite the initial concern of the office manager, he continued with this arrangement for many years and never found it taxing.  His patients, our father’s former patients, seemed genuinely appreciative of the personal touch and, as a result, never abused the privilege of leaving messages for him.  The mere knowledge that they could, if necessary, hear his voice and leave a message for him successfully bridged the transition to a new location and a new staff.

Physicians should impress on their phone receptionists that they not only make appointments but provide new patients with their initial (and perhaps durable) sense of the physician and the staff.  Phone receptionists should understand that patients – especially new patients – are not merely consumers buying a service, but individuals who may be, variously, vulnerable, anxious, and/or in pain.  There is a gravity, however subliminal, in that first phone call and in those first words offered to the would-be patient.  And let there be no doubt:  Many patients still cling to the notion that a medical practice – especially a primary care practice – should be, per Winnicott, a “holding environment,” if only in the minimalist sense that the leap to scheduling an appointment will land one in good and even caring hands.


[1] The first quoted passage is reprinted in P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 123. The second passage is not in the book and is among my father’s personal effects.

[2] L. Macmillan & M. Pringle, “Practice managers and practice management,” BMJ, 304:1672-1674, 1992; L . S. Hill, “Telephone techniques and etiquette: a medical practice staff training tool,” J. Med. Pract. Manage., 3:166-170, 2007; M. Gallagher, et al.,  “Managing patient demand: a qualitative study of appointment making in general practice,” Brit. J. Gen. Pract., 51:280-285, 2001.

[3] See J. L. Austin,  How To Do Things with Words (Cambridge: Harvard University Press, 1962) and the work of his student, J. R. Searle, Speech Acts:  An Essay in the Philosophy of Language. (Cambridge: Cambridge University Press, 1970).

[4] Ainsworth’s typology of mother-infant attachment states grew out of her observational research on mother-infant pairs in Uganda, gathered in her Infancy in Uganda (Baltimore: Johns Hopkins, 1967).  On the nature of secure attachments, see especially J. Bowlby, A Secure Base: Parent-Child Attachment and Healthy Human Development(New York: Basic Books, 1988) and  I. Bretherton, “The origins of attachment theory: John Bowlby and Mary Ainsworth,” Develop. Psychol., 28:759-775, 1992.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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My Father’s Empathy

My late father, William Stepansky, was the most empathic caregiver I have ever known.  Until recently, however, I never thought of him that way.  Indeed, I never had the sense that he “practiced” medicine one way or another, simply that he lived out his medical calling.  I thought nothing of having a father who taped the Hippocratic Oath to his dresser and read it every morning.

My father’s “empathy” did not grow out of medical training; it was the stuff of life experience. His family’s emigration from Russia followed the Hitler-like savagery of the Ukrainian Pogroms that followed World War I.  Anti-Semite thugs murdered his grandfather on his own doorstep several years before his father, Pincus, mother, Vittie (then pregnant with him), and older sister, Enta began their uncertain journey to America in 1921.  Pincus, a highly decorated Russian war veteran, a member of the 118th (Shuiskii) Infantry Regiment of the 30th Infantry Division, was the recipient of what my father termed the Russian equivalent of our own Congressional Medal of Honor.  “He was a sergeant,” he would tell me, “but a colonel had to salute him first.” On the battlefield he was wounded three times in the chest and once left for dead.  Stripped of his decorations by the bandits who raided his native village of Stavishche, he arrived in the new world penurious and crippled with chest pain.

My father, who was born in Kishinev, Rumania during the first leg of his family’s 1,900-mile journey across continental Europe, was six-months old when they arrived in Boston Harbor.  A year later, they left Boston and made their home in the densely Jewish enclave in South Philadelphia.  Throughout my life, my father shared two memories of his own father; they attest, respectively, to the positive and negative poles of the wounded soldier-tailor’s dedication to high culture. The first is of Pincus gamely limping across long city blocks with his young son in tow; he was taking his young son, my father, to his weekly violin lesson with his first teacher, the local postman.  Pincus never left the music room, and when the lesson was over, he took his son’s violin and lovingly wiped it down with a special cloth brought solely for that purpose.

The second memory is of Pincus imperiously ordering his son to bring his violin and perform whenever neighbors, friends, or relations gathered in the family’s small apartment.  A shy, retiring child, my father urgently wanted not to play. But his father’s directives were issued from on high with military-like peremptoriness that brooked neither contradiction nor delay.  And so my father got his violin and he played, perhaps through tears, perhaps through rage.

My father, at age 15, watched his father die of heart disease. In February, 1943, having completed his third-year of pharmacy training, he was called up by the army and served as a surgical technician in a medical battalion attached to the 80th Infantry Division of Patton’s Third Army.  In France, Belgium, and Germany, he worked alongside battlefield surgeons who fought to keep wounded GIs alive in a surgical clearing company only a short remove from the front line.  I learned a bit about the visceral reality of wound management in the European Theatre during his final years, when I interviewed him and several of his surviving comrades for The Last Family Doctor.  The prosaic summary of his duties in his army  discharge of January, 1946 – “Removed uncomplicated cases of shrapnel wounds, administered oxygen and plasma, sterilized instruments, bandages, clothing, etc.  Gave hypodermic injections and performed general first aid duties” – only hints at this reality.

My father, so I learned, held down wounded GIs for anesthesia-less suturing, assisted with frontline battlefield surgery, much of which involved amputation, and then, after the day’s work, went outside to bury severed arms and legs. He experienced close fighting in the woods of Bastogne during the freezing winter of 1945, when the techs worked 20-hour shifts to keep up with the inflow of casualties.  One can only wonder at the impact of such things on the constitution of a gentle and soft-spoken 22-year-old pharmacy student whose passion, before and after the war, was the violin, and who carried Tolstoy’s War and Peace in his backpack throughout his European tour.

A different man might have emerged from my father’s childhood and wartime experience emotionally constricted, withdrawn, intimidated by authority figures or, obversely (or concurrently) enraged by them.  In my father’s case, a lifelong performance anxiety – the legacy of a militaristic father repeatedly ordering him to play violin before visitors — was vastly counterbalanced by an enlarged empathic sensibility that enabled him to understand and contain his patients’ anxieties about their health, their relationships, their ability to love and to work.  Wrestling as he did with his own anxieties and memories of the war, which included the liberation of Dachau and Buchenwald, he became a physician who accepted utterly his patients’ prerogative to share their anxieties with him, even to project their anxieties into him.  He was, after all, their doctor.

My father was not only an astute diagnostician but also a gifted psychotherapist, and the amalgam of these twin talents was an ability to titrate his disclosures, to tell patients what they needed to know, certainly, but in a manner he thought they could bear.  His psychologically attuned approach to patient care is now associated with the paternalism of a different era.  But it was also an aspect of his ability, rare among physicians, to diagnose suffering and to discern the limits of this or that patient’s ability to cope with it.[1]  This style of practice was wonderfully appreciated by his patients, some of whom, after leaving the area, travelled a distance for yearly appointments with him.  No doubt they wanted to experience the “holding environment” of his person.

Premed students who grind away at biology and chemistry have no idea what my father and his cohort of war-tested physicians, many first- and second-generation immigrants, overcame for the privilege of studying medicine.  I would not wish his life story – of which I relate only a few particulars here – on any of them.  And yet, we might ponder the desirability of subjecting premed students to some muted version of his experience in order to nurture whatever elements of empathic temperament they possess.  Specifically, medical educators can take steps to ensure that premeds are not subverted by medicine’s  “hidden curriculum” – its institutional pull away from patient-centered values and practices – while they are still in college, especially when they complete their med school applications and present for their interviews.  And they can work harder to find clinical teachers who do not endorse shame, humiliation, and intimidation as credible educational strategies for acculturating young doctors into the profession.[2]

If we wish to steer contemporary medical students toward compassionate, or at least adequately sensitive, care-giving – and here I echo what others have said[3] – then we need to provide them with clinical teachers who are dissatisfied with a passive conception of role modeling and actually model discrete and specifiable behaviors in their interactions with patients.[4]  Sadly, the literature continues to provide examples of clinical training during medical school and residency that is denigrating, demoralizing, and ultimately desensitizing.  We end up with clinical teachers (not all, by any means, but no doubt a good many) who long ago capitulated to the hidden curriculum and devote themselves to readying the next generation of trainees for a like-minded (or better, a survival-minded) capitulation.  With this intergenerational dynamic in place, we are at the point of Marshall Marinker’s devastating “Myth, Paradox and the Hidden Curriculum” (1997), which begins:  “The ultimate indignity teachers inflict upon students is that, in time, they become us.”[5]

My father and his cohort of med students who trained during and shortly after WWII were resistant to shaming and intimidation.  They had experienced too much to be diverted from a calling to practice medicine.  But then their teachers too had experienced a great deal, many working alongside their future students – the pharmacists, medics, techs, and GIs – in casualty clearing stations, field hospitals, VA hospitals, and rehab facilities in Europe and America.  Teachers emerging from the war years encountered a generation of mature students whose wartime experience primed them to embrace medicine as patient care.  And the students, for their part, encountered teachers whose own wartime experience and nascent cold war anxieties tempered budding Napoleonic complexes.  High tech medicine, bioethics, and patient rights all lay in the future. Generalists like my father were trained to provide care that was caring; their ministrations were largely “medicinal, manual, and mentalistic, which is to say, psychological.”[6]  In the kind of training they received, the notion of  castigating as “unprofessional” med students whose patient-centered concerns and queries slowed down the breakneck pace of team rounds – a documented reality these days[7] – would literally have been non-sensical.

But that was then and this is now.  Today medical culture has in key respects become subversive of the ideals that drew my father and his cohort to medicine.  And this culture, which revolves around the sacrosanctity of an academic hierarchy that, inter alia, insists on perfection, denigrates uncertainty, privileges outcome over process, and, in the clinical years, engages students adversarially, is far too entrenched to be dislodged with manifestos, position papers, and curricular reforms.  What educators can do is seek out medical students whose empowerment derives less from high grades and artfully constructed admissions essays and more from life experience in the trenches – in any trenches. We don’t need to send premeds off to war to make them resistant to the hidden curriculum, but we should encourage premed experience robust enough to deflect its pull and let those of caring temperament develop into caring physicians.

Perhaps we need students who are drawn less to biochemistry than to the vagaries of human chemistry, students who have already undertaken experiential journeys that bring into focus the humanistic skyline of their medical horizons.  What Coulehan[8] terms “socially relevant service-oriented learning” should not be confined to residency training.  We need more students who come to medicine after doing volunteer work in developing nations; fighting for medical civil rights; staffing rural and urban health clinics; and serving public health internships.[9]  And if this suggestion is quixotic, let’s at least have premed students spend the summer before senior year in the trenches, as I proposed in “The Hunt for Caring Med Students.”  Such strategies will not create empathic caregivers de novo, but they will nurture the empathic temperament of those so endowed and, one hopes, fortify them a little better against the careerist blandishments of the hidden curriculum.  It would be nice if, a generation hence, other sons (and daughters) could write about their fathers’ (and mothers’) special kind of therapeutic empathy.


[1] E. J. Cassell, “Diagnosing suffering: a perspective,” Ann. Intern. Med., 131:531-534, 1999.

[2] J. White, et al., “’What do they want me To say?’: the hidden curriculum at work in the medical school selection process: a qualitative study,” BMC Med. Educ., 12:1-9, 2012; U. H. Lindström, et al., “Medical students’ experiences of shame in professional enculturation,” Med. Educ., 45:1016-1024, 2011; A. H. Brainard & H. C. Brislen, “Learning professionalism: a view from the trenches,” Acad. Med., 82:1010-1014, 2007; P. Haidet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians,” J. Gen. Intern. Med., 21:S16-20, 2006; Mary Seabrook, “Intimidation in medical education: students’ and teachers’ perspectives,” Stud. Higher Educ., 29:59-74, 2004.

[3] Haidet & Stein, “Role of the student-teacher relationship”; N. Ratanawongsa, et al., “Residents’ perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements,” J. Gen Intern. Med., 21:758-763, 2006; J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; B. Maheux, et al., “Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools, Med. Educ., 34:630-634, 2000; J. H. Burack, et al., Teaching compassion and respect: attending physicians’ responses to problematic behaviors,” J. Gen. Intern. Med., 14:49-55, 1999.

[4] See further Burack, “Teaching compassion and respect,” p. 54.

[5] M. Marinker, “Myth, paradox and the hidden curriculum,” Med. Educ., 31:293-298, 1997, quoted at p. 293; cf. Haidet & Stein, “Role of student-teacher relationship,” p. 3: “The relational processes of the hidden curriculum assure the perpetuation of its content” (authors’ emphasis).

[6] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 114.

[7] Brainard & Brislen, “Learning professionalism,” p. 1011.

[8] Coulehan, “Today’s professionalism,” p. 896.

[9] For examples of such physicians and their role in the revitalization of primary care medicine in the 1970s, see Stepansky, Last Family Doctor, pp. 130-133.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

Humanitas, History, Empathy

In the nineteenth century, no one was devising courses, workshops, or coding schemes to foster empathic care-giving.  In both Europe and America, students were expected to learn medicine’s existential lessons in the manner they long had:  through mastery of Latin and immersion in ancient writings.  This fact should not surprise us:  knowledge of Latin was the great nineteenth-century signpost of general knowledge.  It was less an index of education achieved than testimony to educability per se.  As such, it was an aspect of cultural endowment essential to anyone aspiring to a learned profession.

I have written elsewhere about the relationship of training in the classics to medical literacy throughout the century.[1]  Here I focus on the “felt” aspect of this cultural endowment: the relationship of classical training to the kind of Humanitas (humanity) that was foundational to empathic caregiving.

The conventional argument has it that the role of Latin in medicine progressively diminished throughout the second half of the nineteenth century, as experimental medicine and laboratory science took hold, first in Germany and Austria, then in France, and finally in Britain and the United States, and transformed the nature of medical training.  During this time, physicians who valued classical learning, so the argument goes, were the older men who clung to what Christopher Lawrence terms “an epistemology of individual experience.”  In Britain, aficionados of the classics were the older, hospital-based people who sought to circumscribe the role of science in clinical practice.  Like their younger colleagues, they used the rhetoric of science to bolster their authority but, unlike the younger men, they “resisted the wholesale conversion of bedside practice into a science – any science.”  For these men, clinical medicine might well be based on science, but its actual practice was “an art which necessitated that its practitioners be the most cultured of men and the most experienced reflectors on the human condition.”[2]

For Lawrence, classical learning signified the gentleman-physician’s association of bedside practice with the breadth of wisdom associated with general medicine; as such, it left them “immune from sins begotten by the narrowness of specialization.”  In America, I believe, the situation was different.  Here the classics did not (or did not only) sustain an older generation intent on dissociating scientific advance from clinical practice.  Rather, in the final decades of the century, the classics sustained the most progressive of our medical educators in their efforts to resist the dehumanization of sick people inherent in specialization and procedural medicine.  Medical educators embraced experimental medicine and laboratory science, to be sure, but they were also intent on molding physicians whose sense of professional self transcended the scientific rendering of the clinical art.  Seen thusly, the classics were more than a pathway to the literacy associated with professional understanding and communication; they were also a humanizing strategy for revivifying the Hippocratic Oath in the face of malfunctioning physiological systems and diseased organs.

Consider the case of Johns Hopkins Medical College, which imported the continental, experimental model to theUnited States and thereby became the country’s first modern medical school in 1892.   In the medical value assigned to the classics, three of Hopkins’ four founding fathers were second to none.  William Welch, the pathologist who headed the founding group of professors (subsequently known as “The Big Four”), only reluctantly began medical training in 1872, since it meant abandoning his first ambition:  to become a Greek tutor and ultimately a professor of classics at his alma mater, Yale University.  Welch’s love of the classics, especially Greek literature and history, spanned his lifetime.  “Everything that moves in the modern world has its roots in Greece,” he opined in 1907.

William Osler, the eminent Professor of Medicine who hailed from the Canadian woodlands north of Toronto, began his education as a rambunctious student at the Barrie Grammar School, where he and two friends earned the appellation “Barrie’s Bad Boys.”  On occasion, the little band would give way to “a zeal for study” that led them after lights-out to “jump out of our dormitory window some six feet above the ground and study our Xenophon, Virgil or Caesar by the light of the full moon.”  Osler moved on to the Trinity College School where, in a curriculum overripe with Latin and the classics, he finished first in his class and received the Chancellor’s Prize of 1866.  Two years later, he capped his premedical education at Trinity College with examination papers on Euclid, Greek (Medea and Hippolytus), Latin Prose, Roman History, Pass Latin (Terence), and Classics (Honours).[3]  Ever mindful of his classical training, Osler not only urged his Hopkins students “to read widely outside of medicine,” but admonished them to “Start at once a bed-side library and spend the last half hour of the day in communion with the saints of humanity,”  among whom he listed Plutarch, Marcus Aurelius, Plato, and Epictetus.[4]

When Howard Kelly, the first Hopkins Professor of Gynecology and arguably the foremost abdominal surgeon of his time, began college in 1873, he was awarded the Universityof Pennsylvania’s matriculate Latin Prize for his thesis, “The Elements of Latin Prose Composition.”  Kelly, like Welch and Osler, was a lifetime lover of the classics, and he relished summer vacations, when he could “catch up on his Virgil and other classics.[5]

Of the fourth Hopkins founding father, the reclusive, morphine-addicted surgeon William Stewart Halsted, there is no evidence of a life-long passion for the ancients, though his grounding in Latin and Greek at Phillips Academy, which he attended from 1863 to 1869, was typically rigorous.  Far more impressive bona fides belong to one of  Halsted’s early trainees, Harvey Cushing, who came to Hopkins in 1897 and became the hospital’s resident surgeon in 1898.  Cushing, the founder of modern neurosurgery, entered Yale in 1887, where he began his college career “walking familiarly in the classics” with courses that included “geometry, Livy, Homer, Cicero, German, Algebra, and Greek prose.”  In February, 1888, he wrote his father that Yale was giving him and his friends “our fill of Cicero.  We have read the Senectute and Amicitia and are reading his letter to Atticus, which are about the hardest Latin prose, and now we have to start in on the orations.”[6]

In the early twentieth century, Latin, no less than high culture in general, fell by the wayside in the effort to create modern “scientific” doctors.  By the 1920s, medical schools had assumed their modern “corporate” form, providing an education that was standardized and mechanized in the manner of factory production.  “The result of specialization,” Kenneth Ludmerer has observed, “was a crowded, highly structured curriculum in which subjects were taught as a series of isolated disciplines rather than as integrated branches of medicine.”[7]  Absent such integration, the very possibility of a holistic grasp of sick people, enriched by study of the classics, was relinquished.

The elimination of Latin from the premed curriculum made eminently good sense to twentieth-century medical educators.  But it was not only the language that went by the wayside.  Gone as well was familiarity with the broader body of myth, literature, and history to which the language opened up.  Gone, that is, was the kind of training that sustained holistic, perhaps even empathic, doctoring.

When in the fall of 1890 – a year after the opening of Johns Hopkins Hospital – Osler and Welch founded the Johns Hopkins Hospital Historical Club, it was with the explicit understanding that medical history, beginning with the Hippocratic and Galenic writings, was a humanizing building block in the formation of a medical identity.  The first year of monthly meetings was devoted exclusively to Greek medicine, with over half of 15 presentations dealing with Hippocrates.  Osler’s two talks dealt, respectively, with “The Aphorisms of Hippocrates” and “Physic and Physicians as Depicted in Plato.”  Over the next three years, the Club’s focus broadened to biography, with Osler himself presenting essays on seven different American physicians, John Morgan, Thomas Bond, Nathan Smith, and William Beaumont, among them.  His colleagues introduced the club to other medical notables, European and American, and explored topics in the history of the specialties, including the history of trephining, the history of lithotomy in women, and the ancient history of rhinoscopy.[8]

The collective delving into history of medicine that took place within the Hopkins Medical History Club not only broadened the horizons of the participates, residents among them.  It also promoted a comfortable fellowship conducive to patient-centered medicine.  The Hopkins professors and their occasional guests were not only leading lights in their respective specialties, but Compleat Physicians deeply immersed in the humanities. Residents and students who attended the meetings of the Club saw their teachers as engaged scholars; they beheld professors who, during the first several years of meetings, introduced them, inter alia, to “The Royal Touch for Scrofula in England,” “The Medicine of Shakespeare,” “The Plagues and Pestilences of the Old Testament,” and “An Old English Medical Poem by Abraham Cowley.”   Professors familiar with doctor-patient relationships throughout history were the very type of positive role models that contemporary medical educators search for in their efforts to counter a “hidden curriculum” that pulls students away from patient-centered values and into a culture of academic hierarchies, cynical mixed-messages, and commercialism.[9]

Medical history clubs were not uncommon in the early decades of the twentieth century.  The Hopkins Club, along with the New York-based Charaka Club founded in 1899, had staying power.  In 1939, the third meeting of the Hopkins Club, which presented a play adapted by Hopkins’ medical librarian Sanford Larkey from William Bullein’s “A Dialogue Against the Fever Pestilence” (1564), drew a crowd of 460.  The following year, when the Hopkins Club celebrated its fiftieth anniversary, Baltimore alone boasted two other medical history clubs: the Osler Society of the Medical and Chirurgical Faculty of the State of Maryland and the Cordell Society of the University of Maryland.[10]

Although medical history clubs are a thing of the past, we see faint echoes of their milieu in contemporary medical student and resident support groups, some modeled on the Balint groups developed by Michael and Enid Balint at London’s Tavistock Clinic in the 1950s.[11]  All such groups seek to provide a safe space for shared reflection and self-examination in relation to physician-patient relationships.  In the late-nineteenth and early-twentieth centuries, history clubs filled this space with topics in medical history.  Their meetings broadened the care-giving sensibility of young physicians by exposing them to pain and suffering, to plagues and pestilences, far beyond the misery of everyday rounds.  Medical history and the broadened “medical self” it evokes and nurtures – now there’s a pathway to empathy.


[1] P. E. Stepansky, “Humanitas: Nineteenth-Century Physicians and the Classics,” presented to the Richardson History of Psychiatry Research Seminar, Weill Cornell Medical College, New York, NY, October 3, 2007.

[2] C. Lawrence, “Incommunicable knowledge: science, technology and the clinical art in Britain, 1850-1914,” J. Contemp. Hist., 20:503-520, 1985, quoted at pp. 504-505, 507.

[3] S. Flexner & J. T. Flexner, William Henry Welch and the Heroic Age of American Medicine (Baltimore:  Johns Hopkins University Press, 1968 [1941]), pp. 63-65, 419-420; H. Cushing, The Life of Sir William Osler (London: Oxford University Press, 1940), pp. 25, 39, 52.

[4] W. Osler, Aequanimitas, with other Addresses to Medical Students, Nurses and Practitioners of Medicine, 3rd edition (New York: McGraw-Hill, 1906), pp. 367, 463; L. F. Barker, Time and the Physician (New York: Putnam, 1942), p. 86.

[5] A. W. Davis, Dr. Kelly of Hopkins: Surgeon, Scientist, Christian (Baltimore: Johns Hopkins University Press, 1959),  pp. 17, 21.

[6] David Linn Edsall, who, as Dean of Harvard Medical School and of the Harvard School of Public Health during the 1920s, engineered Harvard’s progressive transformation, entered Princeton the same year (1887) Cushing entered Yale.  Edsall came to Princeton “a serious-minded young classicist” intent on a career in the classics. See  J. C. Aub & R. K. Hapgood, Pioneer in Modern Medicine: David Linn Edsall of Harvard (Cambridge: Harvard Medical Alumni Association, 1970), p. 7.  On Cushing and the classics, see  E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (New York: Schuman, 1950), p. 20.

[7] K. M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York:  Basic Books, 1985), pp. 256-57, 262.

[8] V. A. McKusick, “The minutes of the Johns Hopkins medical history club, 1890 to 1894,” Bull. Hist. Med., 27:177-181, 1953.

[9] F. W. Hafferty, “Beyond curriculum reform: confronting medicine’s hidden curriculum,” Acad. Med., 73:403-407, 1998;  J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; P. Haldet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians: the hidden curriculum as process,” J. Gen. Int. Med., 21(suppl):S16-S20, 2005; S. Weissman, “Faculty empathy and the hidden curriculum” [letter to the editor], Acad. Med., 87:389, 2012.

[10] O. Temkin, “The Johns Hopkins medical history club,” Bull. Hist. Med., 7:809, 1939; W.R.B., “Johns Hopkins medical history club,” BMJ, 1:1036, 1939.

[11] K. M. Markakis, et al., “The path to professionalism: cultivating humanistic values and attitudes in residency training,” Acad. Med., 75:141-150, 2000; M. Hojat, “Ten approaches for enhancing empathy in health and human services cultures,” J. Health Hum. Serv. Adm., 31:412-450, 2009;  K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.  On contemporary Balint groups, see A. L. Turner & P. L. Malm, “A preliminary investigation of Balint and non-Balint behavioral medicine training,” Fam. Med., 36:114-117,2004; D. Kjeldmand, et al., “Balint training makes GPs thrive better in their job,” Pat. Educ. Couns., 55:230-235, 2004; K. P. Cataldo, et al., “Association between Balint training and physician empathy and work satisfaction,” Fam. Med., 37:328–31, 2005.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.