Category Archives: General

The Politics of Medical Freedom

Winner of an Independent Publisher Books Award Bronze Medal for 2017, Paul Stepansky’s In the Hands of Doctors:  Touch and Trust in Medical Care is now available in paperback and as an eBook.  For the paperback edition, Stepansky has written a new preface, a stirring defense of Obamacare as a path to universal health care in America.  It is given here in its entirety in appreciation of the readers of “Medicine, Health, and History.”

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In the Hands of Doctors:  Touch and Trust in Medical Care

Preface to the Paperback Edition
Copyright © 2017 by Paul E. Stepansky.  All rights reserved.

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 In our time, political speech and writing are largely the defense of the indefensible.
                                         — George Orwell, “Politics and the English Language” (1946)

Now, less than a year after publication of In the Hands of Doctors, the Patient Protection and Affordable Care Act of 2010 (aka Obamacare), which I roundly endorse in this book, is gravely imperiled.  Congressional Republican legislators have joined a Republican President in a commitment to repeal the bill that has provided health insurance to over 20 million previously uninsured Americans.  The legislation thus far presented to replace it by the U.S. Senate  (the “Better Care Reconciliation Act of 2017”) would, according to the Congressional Budget Office, leave 15 million Americans uninsured in 2018 and 22 million by 2026.   Proposed cuts and caps to the Medicaid budget, which are part of the legislation, would, according to the CBO, decrease enrollment in the program by 16% over the next decade.  In brief, these cuts and caps would jeopardize the health and well-being of the one in five Americans and one in three American children dependent on the support provided by Medicaid.  Disabled and other special-needs children as well as elderly nursing home residents would suffer the most.  A Congressional vote simply to repeal Obamacare absent new legislation would have even more catastrophic consequences.
      Congressional opponents of the Affordable Care Act, no less than President Donald Trump, appear to live in a hermetically sealed bubble that makes only grazing contact with the socioeconomic ground below.  They share space in the bubble with colliding political abstractions that they grasp, one after the other, and radio back down to earth.  The political bubble dwellers offer us yet again the palliatives of context-free “medical choice” and “medical freedom” as remedies for the real-world suffering addressed by Obamacare.
     But these terms, as used by politicians, do not speak to the realties of American health care in  2017.  Rather, they hearken back to the era of the Founding Fathers, when issues of health, illness, freedom, and tyranny were much simpler.  Freedom, as the founders understood it, operated only in the intertwined realms of politics and religion.  How could it be otherwise?   Medical intervention did not affect the course of illness; it did not enable people to feel better and live longer and more productive lives.  With the exception of smallpox inoculation, which George Washington wisely made mandatory among colonial troops in the winter of 1777, governmental intrusion into the health of its citizenry was nonexistent, even non-sensical.
     Until roughly the eighth decade of the nineteenth century, you got sick, you recovered (often despite doctoring), you lingered on in sickness, or you died.  They were the options.  Medical freedom, enshrined during the Jacksonian era, meant being free to pick and choose your doctor without any state interference.  So liberty-loving Americans picked and chose among mercury-dosing, bloodletting “regulars,” homeopaths, herbalists, botanical practitioners, eclectics, hydropaths, phrenologists, Christian Scientists, folk healers, and faith healers.   State legislatures stood on the sidelines, rescinding or gutting medical licensing laws and applauding the new pluralism.  It was anarchy, but anarchy in the service of medical freedom of choice.
     Now, mercifully, our notion of medical freedom has been reconfigured by two centuries of medical progress.  We don’t just get sick and die.  We get sick and get medical help, and, mirabile dictu, the help actually helps.  In antebellum America, deaths of young people under 20 accounted for half the national death rate, which was more than three times the death rate today.  Now our children  don’t die of  small pox, cholera, yellow fever, dysentery, typhoid, and pulmonary and respiratory infections before they reach maturity.  When they get sick in early life, their parents take them to the doctor and they almost always get better.  Their parents, on the other hand, especially after reaching middle age, don’t always get better.  So they get ongoing medical attention to help them live longer and more comfortably with chronic conditions such as diabetes, coronary heart disease, inflammatory bowel disease, Parkinson’s, and many forms of cancer.
     When our framers drafted the Constitution, the idea of being free to live a productive and relatively comfortable life with long-term illness did not compute.  You died from diabetes, cancer, bowel obstruction, neurodegenerative disease, and major infections.  Among young women,  such infections included the uterine infection that routinely followed childbirth.  A major heart attack simply killed you.  You didn’t receive dialysis and possibly a kidney transplant when you entered kidney failure.  Major surgery, performed on the kitchen table if you were of means or in a bacteria-infested public hospital if you were not, was rarely attempted because it invariably resulted in massive blood loss, infection, and death.
     So, yes, our framers intended our citizenry to be free of government interference, including the Obamacare “mandate” that impinges on Americans who choose to opt out of the program.  But then, with the arguable exception of Benjamin Franklin, the framers never envisioned a world in which freedom could be extended by access to expert medical care that relieves suffering, often effects cure, and prolongs life.  But then, neither could they envision the enfranchisement of former slaves and women, the progressive income tax, compulsory vaccination, publicly supported health clinics, mass screening for TB, diabetes, and  syphilis, or Medicare and Medicaid.  Throughout the antebellum era, when physicians were reviled by the public and when neither regular medicine nor the rival alternative sects could stem the periodic waves of cholera, yellow fever, and malaria that decimated local populations, it mattered little who provided one’s doctoring.  Many, like the thousands who paid $20.00 for the right to practice Samuel Thomson’s do-it-yourself botanical system, chose to doctor themselves.
     Those who seek repeal of Obamacare without a credible legislative alternative that provides equal, preferably greater, health benefits to all Americans seem challenged by the very idea of medical progress.  Their use of terms like “choice” and “freedom” invokes an eighteenth-century political frame of reference to deprive Americans of a kind of freedom associated with a paradigm-shift that arose only in the final quarter of the nineteenth century.  It was only then that American medicine began its transition to what we think of as modern medicine.  Listerian antisepsis and asepsis; laboratory research in bacteriology, immunology, and pharmacology; laboratory development of specific remedies for specific illnesses; implementation of public health measures informed by bacteriology; modern medical education; and, yes, government regulation to safeguard the public from incompetent practitioners and toxic medications – all were part of the transition.  The Jacksonian impulse persisted into the early twentieth century, flaring up in organized opposition to compulsory childhood vaccination, and  finally petering out in the 1930s, by which time it was universally accepted that scientific medicine was, well, scientific, and, as such, something more than one medical sect among many.
     “We hold these truths to be self-evident,” Thomas Jefferson began the second paragraph of the Declaration of Independence, “that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”  What Jefferson did not stipulate, indeed what he could not stipulate in his time and place, were the hierarchical relationships among these rights.  Now, in the twenty-first century, we are able to go beyond an eighteenth-century mindset in which  “Life, Liberty, and the pursuit of Happiness” functioned as a noun phrase whose unitary import derived from the political tyrannies of King George III and the British parliament.  Now we can place life at the base of the pyramid and declare that quality of life is indelibly linked to liberty and the pursuit of happiness.  To the extent that quality of life is diminished through disease, liberty and the pursuit of happiness are necessarily compromised.  In the twenty-first century, health is life; it is life poised to exercise liberty and pursue happiness to the fullest.
     Why, then,  is it wrong to require all citizens to participate in a national health plan, either directly or through a mandate (i.e., a tax on those who opt out), that safeguards the right of people to  efficacious health care regardless of their financial circumstances, their employment status, and their preexisting medical conditions?  What is it about the Obamacare mandate that has proven so troubling to our legislators?  When you buy a house in this country, you pay local property taxes that support the local public schools.  These taxes function like the mandate:  They have a differential financial impact on people depending on whether they directly benefit from the  system sustained by the tax.  To wit, you pay the tax whether or not you choose to send your children to the public schools, indeed, whether or not you have children at all.  You are obligated to subsidize the public education of children other than your own because public education has been declared a public good by the polity of which you are a part.  The same goes for that portion of local taxes that provides police and fire protection.  We accept a mandate to support policemen and firefighters whether or not we will ever need them, in the knowledge that other members of the community assuredly will.  Similarly, those who opt out of Obamacare should pay a price, because they remain part of a society committed to health as a superordinate value without which liberty and the pursuit of happiness are enfeebled.
     It is inconceivable that the Founding Fathers would have found unconstitutional or unfair or governmentally oppressive a law that provided life-promoting health care that enabled more Americans to discharge the duties of citizenship and live more freely and productively in pursuit of happiness.  They declared that citizens – all of whom, be it noted, were white, propertied males – were entitled to life consistent with the demands and entitlements of representative democracy.  Their pledge, their declaration, was not in support of a compromised life that limited the ability to fulfill those demands and enjoy those entitlements.
     When, in our own time, the word “choice,” as used by Republican politicians, means that millions of Americans who rely on Obamacare will end up leading compromised lives, the word becomes semantically contorted and ethically bankrupt.  The absence of Obamacare does not, ipso facto, empower lower-income, assistance-dependent Americans to buy the comprehensive health insurance they need, especially when the tax credits under legislation proposed thus far provide far less support than the subsidization lower-income families now receive.  Freeing insurers from Obamacare regulations so that they can offer inadequate policies that lower-income Americans can afford to buy does nothing but maximize the medical risks of these financially choice-less Americans.  Here is a fact:  Economic circumstances wipe out the prerogative to make prudent choices in one’s own best interest.  For lower-income Americans, a panoply of inadequate choices is not the pathway to right-minded decision making.  With the Senate’s “Better Care Reconciliation Act,” unveiled in June and updated in July, 2017, millions of low-income Americans, especially those dependent on Obamacare subsidies and Medicaid, would have had an absence of credible and affordable choices for obtaining health care adequate to their needs.  The call simply to repeal the Affordable Care Act, which the Senate has rejected as of this writing, would take us back to a status quo ante when millions of Americans were either priced out of, or completely denied, health coverage.
     Of course, adult citizens may repudiate mainstream health care altogether on the basis of philosophical or religious  predilections.  Christian Scientists and Jehovah’s Witnesses, for example, hold theological beliefs that often lead them to refuse medical treatment.  Certainly, they are free to pursue health through spiritual healing or, in the manner of medieval Christians, to disavow corporeal health and earth-bound life altogether.  But by law they cannot deny their children, who deserve to live to maturity and make their own choices, the healing power of modern medicine, whether it comes in the form of insulin, antibiotics, blood transfusions, or surgery.  Nor should they be allowed to undermine social and political arrangements, codified in law, that support everyone else’s right to pursue life and happiness through twenty-first century medicine.  Those who, prior to the Affordable Care Act, had inadequate insurance or no insurance at all are not struggling to free themselves from the clutches of federal regulation; they are not crying out for new free market health plans through which they can exercise freedom of choice.  Rather, they are struggling to put food on the table and keep themselves and their families healthy.  To this end, they need to be free to avail themselves of what modern medicine has to offer, unencumbered by politically debased notions of freedom and choice.
     At this moment in history, in a fractionated society represented by a President and Congressional leaders whose daily missives bear out George Orwell’s acute observation about the corruption of language brought on by political orthodoxies, In the Hands of Doctors may have a wistful ring.  I hope not.  I am addressing the personal side of health care – the reality of a doctor and patient, alone in a consulting room, often surrounded by high-tech diagnostic aids but always containing those vital low-tech instruments with which one person reaches out to the other:  the physician’s eyes and hands and voice.  The human face of doctoring, which now includes the doctoring of nurse practitioners and physician assistants, remains essential to the success of any doctor-patient relationship, whatever the institutional arrangements that bring together this doctor and this patient, the former to help the latter.
     Endeavoring to understand the several aspects – and possibilities – of the doctor-patient relationship, I write about the nature of clinical caring; the relation between caring and patient trust; the need to recruit and train physicians who can bring this caring sensibility to their patients; the role of empathy in medical caring; and the obligation of medical educators to revivify primary care medicine to meet the critical shortage of frontline physicians within underserved American communities.  These issues will not go away, whatever the fate of Obamacare.
     When federal legislation, through the practical assistance it provides, extends the reach of trusting doctor-patient relationships to the most vulnerable  groups in society, it has a  function that is both binding and enabling.  It fortifies the webbing that underlies the increasingly disparate parts of our national mosaic.  Obamacare, the Children’s Health Insurance Program, Medicaid – these programs do not “bring us together” in a feel good way.  They do, however, prevent a free fall in which the subcommunities and interest groups into which society has decomposed land so far apart they are no longer in hailing distance of one another.  As to the enabling function, a comprehensive medical safety net for all Americans – let’s call it what it is: universal health care – revitalizes political democracy by extending to all Americans a greater possibility of life, liberty, and the pursuit of happiness.  In the everyday world, this pursuit boils down to the ability of more people to stay on the job or to work from home rather than not work at all.  Society benefits, since chronically ill people pursuing happiness under the umbrella of universal health care will better resist the complications and collateral illnesses that follow from their primary illness or illnesses.  Society also benefits by enabling healthier happiness-pursuers to avoid hospitalization and, among the elderly, to push back the time when nursing home care is required.  And finally, society benefits by seeing to it that all children, especially those who are disabled, receive every medical advantage as they traverse their own challenging paths to productive, choice-wielding citizenship.
     Obamacare is a far cry from universal health care, but for all its limitations and current financial straits, it has provided these binding and enabling functions for millions of Americans previously without a medical safety net.  Woe to politicians who shred it in the name of choice, a pleasing vacuity that evades the reality of disease and pain among many who are relieved to have a single avenue of subsidized care where none was previously available.
     Health care should be a national trust; everyone deserves what twenty-first century medicine has to offer, regardless of how much or how little choice can be worked into the offering.  Politicians who feel otherwise are enemies of the polity.  Jefferson, who as president helped set up the first smallpox vaccination clinics in the south and then, in retirement, planned a state-supported clinic to provide free medical care to those who could not afford it, would not have brooked the empty insistence that medical freedom and medical choice, unhinged from socioeconomic reality, trump access to medical care per se.  Nor, for that matter, does choice, whatever it may or may not mean, obviate our moral obligation as a society to see to it that best available treatment, whatever the pathway that leads to it, means treatment rendered by caring doctors willing to know their patients as people.

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In the Hands of Doctors:  Touch and Trust in Medical Care, 1st pbk ed

Paul E. Stepansky

978-0983080770        2016/2017pbk        348pp        $26.95pbk

Release date: September 12, 2017

Order now at Amazon.com

 

 

 

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Food and Candy

No one leaves Montclair’s Human Needs Food Pantry without food.  Even folks from surrounding communities who are not among our registered clientele leave with a bag of groceries, a loaf of bread, often a pastry or a half gallon of juice, and an item or two from the table of donated cans and cartons adjacent to the check-in desk.  Mike sees to it.  He fills out an emergency food slip for anyone who comes through the door.  Then he explains what info the person needs to bring back to him (e.g., a rent receipt) to qualify for weekly groceries. Mike writes out such a slip for one man who brings it to me.  After I tell him that, in addition to his bag of food, he may also take two items from the table and a loaf of bread from the rack, he looks me straight in the eye, squeezes my hand, and with disarming directness says:  “Thank you for feeding me.”

Mike is the director and one of the good guys.  His associate Janet is another remarkably good and caring person.  Mike is a retired police chief who knows all about hunger and need.  I man the front desk, greeting our clients, many now by name, retrieving their file cards, filling out the sign-in forms, and telling them how many supplementary items they may take from the adjacent table and how many breads they may take from the bread rack on the opposite wall.  Then I yell out to Chris the size of the household so that he knows how many bags of groceries to place on his table for them.  I do this over 120 times during a three-hour shift.  Earlier in the day, before the pantry opens its doors to social workers at 12 and then to clients at 12:30, my wife Deane and I wait while Tyrell loads our SUV with the bags we will deliver to our list of clients unable to make it to the pantry – the elderly indigent, sometimes bedridden, often living alone.

This is my world every Tuesday, when I stop trying to understand the connection between medical history and present-day health care and seek out connection with people who need food and all kinds of care, medical and otherwise.  Some future historian can try to place my experience in sociohistorical context.  I simply want to give them food, to ask them how they’re doing, to tell them their children are beautiful, and to wish them a good week.

There is something primal about giving food to people who need it and appreciate getting it, people who are down on their luck but not down on their lives.  “How are you,” I ask the people I serve.  “I am blessed,” they sometimes reply.  Working at the pantry has helped me reengage issues that have nothing to do with scholarly writing, to reorder my priorities in a life-affirming way.  At a time when American political discourse has, in a different, twisted way, turned primal, hateful, exclusionary, it takes me to a place where real-world suffering can be addressed one family at a time through food and the nutrient of human connection.

Giving food to people is cleansing.  It changes the way one feels about food, even the way one shops and eats.  More importantly, it enlarges one’s sense of shared humanity with the low-income folks in one’s own community, almost all of whom, I have found, are dignified, convivial, and grateful.  It takes me away from the sickening world of Donald Trump, whose inborn caring instincts flattened out long ago under the weight of narcissistic bloat.  Our clients offer me a smile, a fist bump, a hand shake, occasionally a hug.  They touch me with their hands but also with their eyes and their words.  They ask me how I’m doing, and – knowing that I am a volunteer – thank me for doing this work, which, some tell me, is “the Lord’s work.”  I do not know these people outside the food pantry.  But within its walls, they are admirable – veterans, working single moms, unemployed or underemployed dads, the disabled, the down on their luck, the elderly indigent, the recently incarcerated.

Yes, we touch one another, and an offering of food and candy is the conduit to the touching.  There is nothing extraordinary about food-mediated touch – it happens all the time, not only in the real world but in the world of medicine as well.  Even Freud, who wanted the psychoanalyst to be as emotionally detached from his patients as the operating surgeon, invited many of his patients to lunch and dinner; he even fed his aristocratic Russian patient Sergei Pankejeff (aka the “Wolf Man”) during their analytic sessions.  Doctors of our own time occasionally give needy patients food or money when food stamps have run out, and it becomes a matter of choosing between food and medication co-pays.  Even nonprofits have gotten into the act.  Through the Fruit and Vegetable Prescription Program (FVRx), for example, physicians now write fresh produce scripts for their low-income patients to fill at local farmers markets.[1]

A tiny Asian woman, well into her 70s but wondrously youthful, marches up to the desk each week and, with warm-hearted brio, greets my coworker and me with:  “Hello beautiful woman and most handsome gentleman.”  When she becomes ill and her neighbor comes to pick up her food, I always send her my love, and when she finally returns some months later, I walk around the desk and we hug. The smiles of some of the  women captivate me, I admit it.  I have complimented several of them so often that they come to the desk smiling and laughing, knowing I will gaze at them for an extra second before turning to my file box.  We have established rapport through a smile and a fleeting gaze of appreciation – an expression of my own gratitude to these women who come to us for food. When I remark to another woman how pretty she looks in her stylish jacket and hat, she almost breaks down, telling me she can’t remember when anyone last paid her a compliment, and that I have made not only her day but her week.

My exchanges with my friend Herb are of a different sort.  He is one of our regulars for whom the pantry is a place not only to receive food but to linger and socialize – a convivial time-out from the lives they will return to. We all know who these folks are and, to a person, we accept their prolonged visits, talk to them supportively, and let them feel at home with us.   At one point Herb shared his multiple health concerns with me, and I responded with, as they say, advice and sympathy.  Herb is, inter alia, an unhappy diabetic, chafing under the weight of seriously poor numbers and recent medical injunctions about diet and lifestyle.  Being an insulin-dependent diabetic myself, I warm to Herb’s plight, and we begin an ongoing dialogue about being diabetic.  But Herb remains irreconcilable and, as if to put the cherry on the icing of his medical misery, he waits for me outside the pantry one day with his most recent medical labs in hand.  Will I look at the report and tell him what it means?  Well, Herb, I’m not a doctor, but sure, why not, let’s take a look at your numbers and see how you’re doing.  Now, a year later,  Herb still takes candy from the basket when he arrives at the desk, but now he looks at me and asks, either with his words or his eyes, how many he may take.   Diabetic self-control was not built in a day.

It is the children especially who affect me.  They come with their mothers or fathers or grandmothers, the babies and toddlers in strollers, the older kids standing patiently in line with the adults.  They usually wait for more than an hour to sign in. When candy or snack bars come our way, we place them in a basket on the desk and – with the adult’s permission – ask the children to help themselves.  But what happens when we have none?  I solved the problem by bringing with me each week a large bag of candy – starbursts and skittles are special favorites – and offering every child a small handful.  I always check with the moms, but with only a few exceptions over the years, they always smile, tell me its fine to give their children candy, and thank me.  I do not have the impression these kids eat candy on a regular basis.  So I become the pantry’s “candy man,” the dispenser of goodies, and the kids are (perhaps) a tad more accepting of the long wait in line, knowing that a special treat awaits them at the desk they will finally arrive at.

A little girl of four, virtually Dickensian in her placid soulfulness, stands silently by my side as I write furiously to complete her mother’s paperwork.  Then, without uttering a word, she lightly places a finger on my forearm.  “I know you’re here, sweetheart,” I remark as I continue to write at breakneck speed.  “As soon as I’m done with Mom’s form, I’ll give you some candy.”  And she waits, and I give her the candy, and she thanks me, takes her mother’s hand, and is off to the counter for their food bags.  I wish a young man of nine or ten a good school year and extend my hand.  He takes it and looks up mildly startled because the hand that clasped his own is filled with starbursts.  Another little girl is so exhilarated with her handful of starbursts that she runs around the pantry, crying out for all to hear, “I have a cherry, and I have a grape, and I have a lemon, and I have an orange.”  A little fellow of six or seven stares long and hard at the large basket of candy on the desk and gingerly takes a single small piece.  “Take more,” I urge him. “Take a few.  Go ahead.”  “No, it’s okay,” he replies.  “One is enough.”  But it’s not, not on my watch.  So I tell him to come around the desk where I am sitting and reach back for my big bag of candy, and then I instruct him, warmly but firmly, to take a handful.  He seems momentarily confused, but then slowly, deliberately, reaches down into the bag and emerges with a handful of treats.  “See,” I tell him, “that wasn’t so hard, was it?”  To which he leans in closely and whispers into my ear, “I only took a little handful.”

Giving food to adults and candy to children is no small matter.  It is a relational cement that binds us to others.  When friends or relations or colleagues or acquaintances experience major life events, good or bad, we send them food baskets.  When we want to acknowledge a special kindness or favor, we send food.  We express condolences through food, and we express loving gratitude as well.  Growing up the son of a beloved small-town family doctor in the 1950s and ’60s, I well remember the steady flow of home-baked goods that transformed our kitchen into a bakery every holiday season.  The cakes, pies, and cookies not only expressed gratitude for medical care; they reaffirmed a human connection made tangible through the very sweetness of their baked offerings.  As such, they affirmed my father in his calling as physician and healer.  So it is with the children at the food pantry.  When we offer a low-income child a bit of candy, we convey our appreciation of the child’s essential rightness and affirm the beautiful potential that inheres in this or that child, which is to say in any child.

So here is my advice to anyone repulsed by what has passed as presidential politics these past several months.  Go to your community food pantry or food bank or soup kitchen and become a volunteer.  Connect with the adults and connect with the children, and make sure to bring your own candy to give the kids.  Enter their lives and learn from them about your own.  In giving food to those who need it, you will feed your own humanity, and it is arguable which party to the transaction goes home better nourished.

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[1] See  Danielle Ofri, “When Doctors Give Patients Money” (http://well.blogs.nytimes.com/2014/01/30/when-doctors-give-patients-money/?_r=0) and Sally Wadyka, “Food as Medicine:  Why Doctors are Writing Prescriptions for Produce” (http://blog.foodnetwork.com/healthyeats/2015/03/26/food-as-medicine-why-doctors-are-writing-prescriptions-for-produce/).

Copyright © 2016 by Paul E. Stepansky.  All rights reserved.

PRAISE FOR PAUL STEPANSKY’S  IN THE HANDS OF DOCTORS: TOUCH AND TRUST IN MEDICAL CARE  (PRAEGER, 2016).

       “This book takes many conversations occurring in the world of medicine and reframes them in historical perspective. The result is a body of work with pearls of wisdom strung between the pages. . . . In the Hands of Doctors is an engaging and relevant read for anyone interested in the nuances of the doctor-patient relationship; a historical framework for understanding today’s questions in the medical humanities; or a thoughtful narrative on cultivating humanity in the modern practice of medicine.”   – Ali Rae, review on the website of The Arnold P. Gold Foundation

       “An engaging, richly documented, brilliant critique of the bond between doctor and patient, ranging from classical times through the present. The need for the bond continues, Stepansky argues; patients trust doctors, not teams, medical homes or health care systems. . . . This is a superb introduction to the role of the doctor in a continuing historical context.”- Rosemary Stevens, Ph.D., DeWitt Wallace Distinguished Scholar, Weill Cornell Medical College

       “Paul Stepansky’s In the Hands of Doctors is a unique and compelling reexamination of American medical practice and patient expectations in historical and cultural context.  Examining the many ways in which we seek health, literally from the doctor’s touch, Stepansky draws on his skills as a respected cultural historian and his perspective growing up the son of a rural general practitioner in the 1950s and 1960s. The result is a multilayered, nuanced, and accessible study that focuses on what physicians have offered and patients have sought, especially since the Second World War. . . . This book deserves a wide audience not only of health practitioners and patients, but also of medical historians and medical humanities scholars.” – Howard I. Kushner, Ph.D., Nat C. Robertson Distinguished Professor, Emeritus, Rollins School of Public Health, Emory University

available from Amazon.com and other online sellers

Why I Care About Caring

When it comes to doctoring in America, there is a long-established and growing rift between being well treated and feeling well cared for.  On the one hand, patients want doctors who know them and are caring of them. They are frustrated with the kind of care dispensed in very brief office visits. They are unhappy having their bodies parsed into organs and systems that elicit matter-of-fact diagnoses and impersonally rendered treatments. They may want the “facts,” but they want them conveyed by a human being who understands their apprehension, uncertainty, and confusion in the face of them. The facts are never neutral in their psychological impact on the patient’s sense of self. They establish that the patient is in some manner and to some degree damaged, and therefore in need of a physician able to bring expert knowledge to bear in helping the patient overcome his illness and dis-ease and regain his peace of mind and wholeness. This means that patients expect their physicians to be able and willing to give them enough time to come to know them as persons whose apprehension, uncertainty, and confusion are deeply personal. To the extent that the doctor humanizes the encounter by providing the patient with sympathy and support, perhaps even empathy, the patient feels he is in the hands of a knowing and caring doctor. This is the viewpoint of the bioethicist Edmund Pellegrino.

On the other hand, patients expect their doctors to respect their right to make their own medical decisions. And they want doctors who not only grant them autonomy in principle but cede autonomy in action.  In order to make informed decisions about their bodies, they need the facts, all of them. And so patients expect to be told, directly, perhaps even collegially, what may ensue if they accept or reject one or another of the treatment recommendations that follow from the facts.  But that is where medical care ends. The patient alone must decide what to do with the facts of the matter, the facts of his or her bodily matter as the doctor has scientifically arrived at them.  Armed with information, explanation, and expert risk assessment, the patient will choose a course of treatment, which the physician and/or his colleagues will then implement to the best of their ability. To the extent the physician implements the patient’s treatment plan absent any intrusion of his or her own preferences and values, he or she treats the patient well and truly, and leaves the patient, in turn, feeling well treated and well cared for.  This is the perspective of the bioethicist Robert Veatch.

Between these polar viewpoints on what it means to be a doctor and a patient, respectively, I interpose the notion of medical caring, which is less simple than it appears.  Medical caring can humanize the doctor-patient relationship without imposing values and goals that are antithetical to the patient.  At its best, medical caring is a reaching out to the patient that transcends the banalities (and uncertainties) of diagnosis and treatment in ways that patients throughout history have welcomed, and this because patienthood often compromises personhood.  Here I side with Pellegrino:  In some primal way, we call on doctors when we feel not fully ourselves, or less than ourselves, or anxious about our ability to remain ourselves, and we look to doctors to return us to the normal selves we want to be.

Medical caring has its own historical trajectory; it is responsive not only to the medical knowledge of a given time and place, but also to the cultural and political arrangements through which a society provides for the coming together of doctors and patients. It is from these arrangements that the mindsets of patients and doctors arise and, with varying degrees of success, arrive at a concordant notion of what it means for the one to be in the care of the other.

In a society that increasingly commands patient empowerment in the service of unilateral decision making, a focal concern with medical caring adds the cautionary reminder that we deprive physicians of their own right to counsel, admonish, and persuade at our peril. At a certain point, however variable among different patients and different doctors, the legal assertion of rights begins to undermine the doctor’s prerogative to doctor in ways responsive to the patient’s needs and expectations. Doctors, after all, are also moral agents with a Hippocratic obligation to draw on their humanity, however flawed, in ministering to their patients.  And patients, for their part, have the right to rely on physicians in ways that are human but not strictly factual as to diagnosis and treatment. To relinquish voluntarily a measure of autonomy to a trusted physician is an act of autonomy.

The notion of medical caring captures the sense that doctors are not just “doctors” in some timeless, generic sense, any more than patients are just generic purchasers of medical treatment as a commodity.  The same doctors who, mindful of patient rights, seek to make contact with their patients in more than bland informational ways are themselves the patients of other doctors, as are their loved ones, so the predicament of the patient, whose decision-making autonomy is often compromised, will not be so alien to the doctor as proponents of value-free medicine believe.  Doctors are all patients, or patients in potentia. And patients, for their part, come in all shapes and sizes, maturationally, temperamentally, characterologically, and otherwise.  Some will neither want nor possess the ability to be autonomous decision makers. In a caring relationship, doctor and patient together, with or without participation of the patient’s significant others, make the determination together, person to person.

A historical perspective on medical caring is cautionary in another respect. It reminds us that concepts such as “paternalism” and “autonomy” are themselves historical constructs, not timeless Platonic forms. Bioethicists who use these terms in essentialist ways overlook the historical and cultural location of doctor-patient relationships. The “paternalism” of physicians in ancient Rome, in Renaissance Florence, in seventeenth-century Paris, in nineteenth-century London, in postbellum America, in America of the mid- twentieth century – these are not the same thing.  And none of them is tantamount to what paternalism – or maternalism, or avuncular regard or brotherly or sisterly concern – may still mean in an age of digital medicine, the internet, and patient rights.

It bears remembering, finally, that the feeling of being well cared for by a doctor is responsive not only to the treatment options of a given time and place, but also to cultural assumptions that enter into doctor-patient relationships. Different norms of caring typify different periods in the history of medicine. Patients in the eighteenth century who were bled to syncope (fainting) felt well cared for. Several decades into the nineteenth century, many insisted on being bled, and some would seek out new doctors when their own refused to drain them further. Plenty of caring surgeons of the late nineteenth century applied vaginal leeches and performed ovariotomy on women who, without signs of serious gynecological disease, demanded that doctors recognize their complaints and do something to relieve their suffering. Within a medical paradigm in which even minor pelvic abnormalities explained symptoms of depression and nervous exhaustion (neurasthenia), surgery counted as a caring intervention and was widely understood as such.  Similarly, paternalistic obstetricians of the late nineteenth century who treated postpartum women suffering from exhaustion and agitated depression (“puerperal insanity”) by legitimating their symptoms and ordering compulsory “time outs” from stifling domestic obligations were caring physicians within the gendered constraints of Victorian society.  Prefrontal lobotomy was widely considered a caring intervention for schizophrenics during the 1930s and ’40s.  The surgery, for its many proponents, restored a measure of function (however compromised) to patients who would otherwise have ossified in the chronic wards of mental hospitals.  Now the care of schizophrenic patients is far different and, from a twenty-first century vantage point, far more humane.

But this is beside the point.  It is easy to dismiss bleeding to syncope, vaginal leeching, prefrontal lobotomy, and innumerable other treatments as relics of the past, misguided, unscientific, often harmful. But such judgments, such exercises in presentism, do not negate the caring intent with which such treatments were administered by doctors and received by patients.  There is more to medical caring than meets the contemporary eye.  This is why my forthcoming book, In the Hands of Doctors: Touch and Trust in Medical Care,** puts aside the triumphal march of medical treatment in the nineteenth and twentieth centuries and focuses instead on the history of caring and feeling cared for.  It is with respect to these intertwined dimensions of doctoring that the past is more than past.  The period in American history covered in the book, roughly from the end of the American Civil War through the 1960s – guides us to a deeper understanding of what “modern” patients want and expect from doctors and what, if anything, their doctors can do for them beyond diagnose and treat.

By mining the vagaries of caring and feeling cared for over time, we gain historical perspective and move a little closer to the intersubjective bedrock of what it has meant, and continues to mean, to be a doctor and to place oneself in the doctor’s hands.  What we discern can be unsettling, as the examples above suggest. But taken together, they provide a luminous counterpoise to the progressively depersonalized, cost-driven, productivity-obsessed medicine of the past 40 years.  I offer my work as an example of how thinking with history validates Francis Peabody’s tired but never tiresome insistence that “the secret of the care of the patient is in caring for the patient.”

**Paul E. Stepansky, In the Hands of Doctors:  Touch and Trust in Medical Care (Santa Barbara:  Praeger Publishers, scheduled for release in May, 2016).

Copyright © 2015 by Paul E. Stepansky.  All rights reserved.

The Times They Are a-Changin’: Trends in Medical Education

Medical educators certainly have their differences, but one still discerns an emerging consensus about the kind of changes that will improve healthcare delivery and simultaneously re-humanize physician-patient encounters.  Here are a few of the most progressive trends in medical education, along with brief glosses that serve to recapitulate certain themes of previous postings.

Contemporary medical training stresses the importance of teamwork and militates against the traditional narcissistic investment in solo expertise.  Teamwork, which relies on the contributions of nonphysician midlevel providers, works against the legacy of socialization that, for many generations, rendered physicians “unfit” for teamwork.  The trend now is to re-vision training so that the physician becomes fit for a new kind of collaborative endeavor.  It is teamwork, when all is said and done, that “transfers the bulk of our work from the realm of guesswork and conjecture to one in which certainty and exactitude may be at least approached.”  Must group practice militate against personalized care?  Perhaps not. Recently, medical groups large and small have been enjoined to remember that “a considerable proportion of the physician’s work is not the practice of medicine at all.  It consists of counseling, orienting, extricating, encouraging, solacing, sympathizing, understanding.”

Contemporary medical training understands that the patient him- or herself has become, and by rights ought to be, a member of the healthcare team.  Medical educators ceded long ago that patients, in their own best interests, “should know something about the human body.”  Now we have more concrete expressions of this requirement, viz., that  if more adequate teaching of anatomy and physiology were provided in secondary schools, “physicians will profit and patients will prosper.”   “Just because a man is ill,” notes one educator, “is no reason why he should stop using his mind,” especially as he [i.e., the patient] is the important factor in the solution of his problem, not the doctor.”  For many educators the knowledgeable patient is not only a member of the “team,” but the physician’s bonafide collaborator.  They assume, that is, that physician and patient “will be able to work together intelligently.”  Working together intelligently suggests a “frank cooperation” in which physician and patient alike have “free access to all outside sources of help and expert knowledge.”  It also means recognizing, without prejudice or personal affront,  that the patient’s “inalienable right is to consult as many physicians as he chooses.”  Even today, an educator observes, “doctors have too much property interest in their patients,” despite the fact that patients find their pronouncements something less than, shall we say, “oracular.”  Contemporary training inherits the mantle of the patient rights revolution of the 1970s and 80s.  Educators today recognize that “It is the patient who must decide the validity of opinion from consideration of its source and probability.”  Another speaks for many in reiterating that

It is the patient who must decide the validity of opinion from consideration of its source and probability.  If the doctor’s opinion does not seem reasonable, or if the bias of it, due to temperament or personal and professional experience is obvious, then it is well for the patient to get another opinion, and the doctor has no right to be incensed or humiliated by such action.

Contemporary medical training stresses the importance of primary care values that are lineal descendants of old-style general practice.  This trend grows out of the realization that a physician “can take care of a patient without caring for him,” that the man or woman publicly considered a “good doctor” is invariably the doctor who will “find something in a sick person that aroused his sympathy, excited his admiration, or moved his compassion.”  Optimally, commentators suggest,  multispecialty and subspecialty groups would retain their own patient-centered generalists – call them, perhaps, “therapeutists”  — to provide integrative patient care beyond diagnostic problem-solving and even beyond the conventional treatment modalities of the group.  The group-based therapeutist, while trained in the root specialty of his colleagues, would also have specialized knowledge of alternative treatments outside the specialty.  He would, for example, supplement familiarity with mainstream drug therapies with a whole-patient, one might say a “wholesome” distrust of drugs.

Contemporary training finally recognizes the importance of first-hand experience of illness in inculcating the values that make for “good doctoring.”  Indeed, innovative curricula now land medical students in the emergency rooms and clinics with (feigned) symptoms and histories that invite discomfiting and sometimes lengthy interventions.  Why has it taken educators so long to enlarge the curriculum in this humanizing manner?  If, as one educator notes, “It is too much to ask of a physician that he himself should have had an enigmatic illness,” it should still be a guiding heuristic that “any illness makes him a better doctor.”  Another adds:  “It is said that an ill doctor is a pathetic sight; but one who has been ill and has recovered has had an affective experience which he can utilize to the advantage of his patients.”

The affective side of a personal illness experience may entail first-hand experience of medicine’s dehumanizing “hidden curriculum.”  Fortunate the patient whose physician has undergone his or her own medical odyssey, so that life experience vivifies the commonplace reported by one seriously ill provider:  “ I felt I had not been treated like a human being.”  A physician-writer who experienced obscure, long-term infectious illness early in his career and was shunted from consultant to consultant understands far better than healthy colleagues that physicians “are so prone to occupy themselves with the theoretical requirements of a case that they lose sight entirely of the human being and his life story.”  Here is the painful reminiscence of another ill physician of more literary bent:

There had been no inquiry of plans or prospects, no solicitude for ambitious or desires, no interest in the spirit of the man whose engine was signaling for gas and oil.  That day I determined never to sentence a person on sight, for life or to death.

Contemporary medical training increasingly recognizes that all medicine is, to one degree or another, psychiatric medicine.  Clinical opinions, educators remind us, can be truthful but still contoured to the personality, especially the psychological needs, of the patient.  Sad to say, the best clinical educators are those who know colleagues, whatever their specialty, who either “do not appreciate that constituent of personality which psychologists call the affects . . . and the importance of the role which these affects or emotions play in conditioning [the patient’s] destiny, well or ill, or they refuse to be taught by observation and experience.”   This realization segues into the role of psychiatric training in medical education, certainly for physicians engaged in primary care, but really for all physicians.  Among other things, such training “would teach him [or her] that disease cannot be standardized, that the individual must be considered first, then the disease.”  Even among patients with typical illnesses, psychiatric training can help physicians understand idiosyncratic reactions to standard treatment protocols.  It aids comprehension  of the individual “who happens to have a very common disease in his own very personal manner.”

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These trends encapsulate the reflections and recommendations of progressive medical educators responsive to the public demand for more humane and humanizing physicians. The trends are also responsive to the mounting burnout of physicians – especially primary care physicians – who, in the  cost-conscious, productivity-driven, and regulatory climate of our time, find it harder than ever to practice patient-centered medicine.  But are these trends really so contemporary?  I confess to a deception.  The foregoing paraphrases, quotations, and recommendations are not from contemporary educators at all.  They are culled from the popular essays of a single physician, the pioneer neurologist Joseph Collins, all of which were published in Harper’s Monthly between 1924 and 1929.[1]

Collins is a fascinating figure.  An 1888 graduate of New York University Medical College, he attended medical school and began his practice burdened with serious, sometimes debilitating, pulmonary and abdominal symptoms that had him run the gauntlet of consultant diagnoses – pneumonia, pulmonary tuberculosis, “tuberculosis of the kidney,” chronic appendicitis, even brain tumor.  None of these authoritative pronouncements was on the mark, but taken together they left Collins highly critical of his own profession and pushed him in the direction of holistic, collaborative, patient-centered medicine.  After an extended period of general practice, he segued into the emerging specialty of neurology (then termed neuropsychiatry) and, with his colleagues Joseph Fraenkel and Pearce Bailey, founded the New York Neurological Institute in 1909.  Collins’s career as a neurologist never dislodged his commitment to  generalist patient-centered care. Indeed, the neurologist, as he understood the specialty in 1911, was the generalist best suited to treat chronic disease of any sort.[2]

Collin’s colorful, multifaceted career as a popular medical writer and literary critic is beyond the scope of this essay.[3]  I use him here to circle back to a cardinal point of previous writings.  “Patient-centered/relationship-centered care,” humanistic medicine, empathic caregiving, behavioral adjustments to the reality of patients’ rights  – these additives to the medical school curriculum are as old as they are new.  What is new is the relatively recent effort to cultivate such sensibilities through curricular innovations.  Taken together,  public health, preventive medicine, childhood vaccination, and modern antibiotic therapy have (mercifully) cut short the kind of  experiential journey that for Collins secured the humanistic moorings of the biomedical imperative.  Now medical educators rely on communication skills training, empathy-promoting protocols, core-skills workshops, and seminars on “The Healer’s Art” to close the circle, rescue medical students from evidence-based and protocol-driven overkill, and bring them back in line with Collins’s hard-won precepts.

It is not quite right to observe that these precepts apply equally to Collins’s time and our own.  They give expression to the care-giving impulse, to the ancient injunction to cure through caring (the Latin curare) that, in all its ebb and flow, whether as figure or ground, weaves through the fabric of medical history writ large.  Listen to Collins one final time as he expounds his philosophy of practice in 1926:

It would be a wise thing to devote a part of medical education to the mind of the physician himself, especially as it concerns his patients.  For the glories of medical history are the humanized physicians.  Science will always fall short; but compassion covereth all.[4]


[1] Joseph Collins, “The alienist in court,” Harper’s Monthly, 150:280-286, 1924; Joseph Collins, “A doctor looks at doctors,” Harper’s Monthly, 154:348-356, 1926; Joseph Collins, “Should doctors tell the truth?”, Harper’s Monthly, 155:320-326, 1927;  Joseph Collins, “Group practice in medicine,” Harper’s Monthly, 158:165-173, 1928;  Joseph Collins, “The patient’s dilemma,” Harper’s Monthly, 159:505-514, 1929.   I have also consulted two of Collins’s popular collections that make many of the same points:  Letters to a Neurologist, 2nd series (NY: Wood, 1910) and The Way with the Nerves: Letters to a Neurologist on Various Modern Nervous Ailments, Real and Fancied, with Replies Thereto Telling of their Nature and Treatment (NY: Putnam, 1911).

[2] Collins, The Way with Nerves, p. 268.

[3] Collins’s review of James Joyce’s Ulysses, the first by an American, was published  in The New York Times on May 28, 1922.  His volume The Doctor Looks at Literature: Psychological Studies of Life and Literature (NY: Doran, 1923) appeared the following year.

[4] Collins, “A doctor looks at doctors,” p. 356.  Collins’s injunction is exemplified in “The Healer’s Art,” a course developed by Dr. Rachel Naomi Remen over the past 22 years and currently taught annually in 71  American medical colleges as well as medical colleges in seven other countries.  See David Bornstein, “Medicine’s Search for Meaning,” posted for The New York Times/Opinionator on September 18, 2013 (http://opinionator.blogs.nytimes.com/2013/09/18/medicines-search-for-meaning/?_r=0).

Copyright © 2013 by Paul E. Stepansky.  All rights reserved.

It Takes a Village in Health Care, Too

It Takes a Village in Health Care, Too

David W. Stepansky, M.D.**

A few weeks ago, while rounding on patients at Phoenixville Hospital, I began to experience a vague tightness in my upper chest as I walked from one nurses’ station to the next.  The pain was fairly mild, but I also became a little sweaty with it.  The symptoms did not cause me to stop and rest, but when I did sit down to write on a chart, the discomfort would subside, only to recur when I began walking again.

As a physician, I well knew what my symptoms might have represented, but being just as susceptible to denial as any other human, I chose to ignore things for a little while, not wanting to believe that I might be experiencing angina.  I knew what would take place as soon as I said anything to anyone and only wanted to forget that it was happening.  I actually went out to my car to drive to the office to start my outpatient hours, again experiencing that same mild but gnawing pressure in my chest.  I sat in my car for a minute or two, just trying to think it all through, when I finally came to the realization that if I was indeed ignoring cardiac symptoms, than I was being very foolish.

Even then, I did not go directly to the emergency room.  Instead, I wandered through the hospital until I found one of my cardiologist partners and told him my story. Of course, from that moment on, I ceased to be a doctor and somewhat begrudgingly became a patient.  I knew from that moment that I would have to  completely relinquish my regular identity and become wholly reliant not only on the judgment and skill, but also on the compassion of the many who then began to care for me.

What happened after that was at once extraordinary and commonplace. Following my evaluation in the emergency room, I was taken directly to the cath lab where a 95% occlusion of my circumflex artery was discovered and uneventfully stented.  I recuperated in the post-op area, was transferred briefly to an inpatient room, and was ultimately discharged at 6:00 PM.  In the aftermath of this whirlwind, surreal day, I found myself at home safe, healed, and marveling with my wife at how I had had my heart fixed from a tiny hole in my wrist.  All that remained was for me to take it easy for a few days, contemplate how my life had changed, and reflect on this stark and jolting recognition of my own frailty.

The care that I received while a patient at the hospital was wonderful – efficient, accurate, and at the same time compassionate and reassuring.  As an attending physician at Phoenixville Hospital for over 30 years, as well as the organization’s CMO and Patient Safety Officer, I have spent countless hours in countless meetings overseeing the hospital’s quality and safety.  Yet experiencing the care provided from this new (and hopefully not oft repeated) vantage point was eye-opening in some unexpected ways.

In particular, I was repeatedly struck by the realization that exemplary health care is truly the sum total of the well-intended, expert actions of a multitude of people.  With due gratitude to, and respect for, the talented physicians who cared for me, their actions would not have been possible without the support of a highly competent and reliable team that comprised both people and machines.  I was repeatedly impressed and comforted by the confident attitudes of nearly everyone I encountered.  Some of these people I knew well and some I had never seen before.  The people who participated in my care, aside from my doctors, included ER nurses, x-ray technicians, laboratory technicians, cath lab personnel, post-op nurses, and telemetry nurses.  But this barely scratches the surface when one considers that the technology brought to bear on me was developed and refined by scores of dedicated individuals whose ultimate purpose was to provide accurate and safe healing to individuals like me.  In many ways, this was a humbling experience, as I must be thankful to a multitude of people, most of whom are actually behind the scenes and will never be known to me.

Many individuals who are involved in the front line of health care, including me, worry about the dehumanizing effect that high technology and specialization has had on patient care.  Doctors and the systems in which they work are so often criticized for being aloof and insensitive to the emotional needs of patients. Health care has become highly business-oriented, often at the expense of the human needs of those for whom the system ostensibly came into being.  Unfortunately, there is much truth to this concern.

However, the realization that I had during my brief hospital stay was that the human aspects of health care can be maintained even in the face of “dehumanizing” technology.  Doctors do less “hand holding” than in the past, but this is at least in part because there is so much more they can do.  Patients expect, and are entitled to, the high technology that modern medicine brings to them,  but they are also  entitled to  the warmth and  caring of the people who deploy that technology on their behalf.  I can happily report that I received both when I was ill.  It was, once again, an eye-opening experience.

The reality is that high-quality health care can only be the result of painstaking design.  The care that I received could never happen were it not for the coordinated actions of hundreds of dedicated individuals.  And so I would like to acknowledge the many people and machines that brought me back to good health.  To my doctors, nurses, technicians and others who provided efficient and compassionate care; to the many people behind the scenes whom I will never know who also contributed to my well-being; and finally to Community Health Systems for providing the structure necessary for all of this to happen – my heartfelt thanks.

Copyright © 2013 by David W. Stepansky.  All rights reserved.

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**Internist David Stepansky is Chief Medical Officer and Patient Safety Officer at Phoenixville Hospital, Phoenixville, PA, and Chair of the Patient Safety Committee of Community Health Systems, Inc., Franklin, TN.

A Musical Offering

“There is no doubt in my mind that the study of music aids in the study of medicine.  The study of one appears to potentiate the other.”                                  ~ F. William Sunderman, M.D., Musical Notes of a Physician (1982)

My father, William Stepansky, whose lifelong passion for violin and string chamber playing is recorded in The Last Family Doctor, holds a singular status in the history of World War II.  He was the only GI in the US Army to join his infantry division at the D-Day staging area in the dripping heat of Yuma, Arizona with a violin in tow.  Wiser minds prevailed, and he sent the violin home, but not before knowledge of his unlikely traveling companion spread throughout the unit.  Here he is in army fatigues playing violin in Germany in the final year of World War II.  The violin in question, a fine mid-eighteenth-century instrument by the Prague maker Thomas Andreas Hulinzky (1731-1788), was the gift of a group of GIs who retrieved it in the vicinity of the famous Hohner Factory in Trossingen, Germany in early 1945.  Apparently knowing about the violin-toting  kid from South Philly who was a surgical tech, they brought the “liberated” fiddle back to his surgical clearing station and offered it to him – but only on condition that he play it for them then and there.

He obliged them, and the Hulinzky became his violin for the next half century, the instrument that provided his four sons with childhoods suffused with Bach, Mozart, Beethoven, Schubert, Mendelssohn, Brahms, and a host of later Romantics.  We learned standard repertoire through my father’s practicing and chamber rehearsals and performances.  And we played with him ourselves – two pianists, a violinist, and a cellist.   Here is a family trio in action in 1976; this one includes David Stepansky (piano), Alan Stepansky (cello), and William Stepansky (violin).

Why the violin mattered so much to our father and how it entered into the kind of medicine he practiced – I forego these precious bits of biography here.  But I cannot resist commenting on Danielle Ofri’s recent piece, “Music Teachers for Doctors?”, since it stimulates memories of growing up with a  gifted physician-musician in a remarkably musical household.

Picking up on a recent article by the internist Frank Davidoff, Ofri suggests that the critical feedback that performing musicians receive throughout their careers from “teachers, audiences, critics and their own ears” exemplifies the kind of “coaching” that, in parallel fashion, might aid physicians in the “performance” of clinical medicine.  Senior colleagues who observe physicians as they actually practice medicine and provide “detailed feedback,” she suggests, might play the same energizing motivational role as music teachers and coaches who relentlessly critique their students’ performance skills and spur them to higher levels of artistry.

It’s a bit difficult to understand precisely what Ofri and Davidoff mean by the term “performance.”  It seems to be a catchall for clinical competence, of which creative problem solving; emotional engagement;  collaborative sensibility; and enthusiasm for the work are all components.  The greater one’s allotment of these attributes, the better one “performs” clinical medicine.

Davidoff, who observes that most musicians “perform almost exclusively in groups,” is especially taken with the interactive and cognitive yield of group performance.  It inculcates a better sense of “teamwork,” of the “specialization” associated with one’s particular instrument, and of the importance of clinical improvisation, i.e., the wherewithal to deviate from established protocols in response to the needs of “particular patients in particular contexts.”  Ofri, for her part, sees clinical coaching modeled on musical coaching as especially relevant to the creeping complacency, the mid-career “plateaus” to which all-too-human physicians are subject.  Musical-cum-clinical coaching would remind physicians that the quest for “performance” excellence is never ending; it might goad them to further career growth and renewed satisfaction in their work.

Between these two contrasting emphases, I am more aligned with Davidoff, though I question whether the value of group performance is best thought of in terms of an interactional concept such as “teamwork” or a cognitive skill such as improvisation.  The improvement to which “good enough” doctors  should seek ongoing feedback is of a different sort.   What they could really use is a dose of the sensibility associated with chamber music playing, for ensemble work feeds into the art and craft of dialogue, of give and take, of respectful recognition of different voices moving together in accord with the anatomical blueprint provided by a composer.

Rather than provide “coaches” who give physicians feedback to improve their clinical “performance,” let’s take them right to the medicomusical locus itself.  To wit, let’s make instrumental training and chamber performance an integral part of postgraduate clinical training.  And, by way of bringing this utterly fanciful notion back down to earth – or at least within earth’s orbit – let’s give physicians “continuing education” credit both for playing in musical ensembles and for taking seminars and workshops on how to listen to chamber music.

But let’s play out the original fantasy.  What a boon to patients if doctors were obliged to make music among themselves.  Better still if they made music with nonphysicians and best of all if they made music with current or former patients.  In so doing, they might build up tacit knowledge relevant to caring for people rather than diagnosing and treating illnesses.  From chamber playing, they would learn about harmonious interchange, about counterpoint (as Davidoff points out), about respecting intelligent voices other than their own.  Tacit knowledge – the concept comes to us from the Hungarian-British scientist and philosopher Michael Polanyi – by its nature resists articulation among those who possess it.  But, speaking from the outside, let me say that the tacit knowledge I have in mind hovers around the art of doctor-patient communication, of learning to converse with patients in a manner more responsive to individual illness experiences.  Here is my claim:  Chamber music holds the promise of broadening, however tacitly, the physician’s sense of dialogic possibility when he or she is with patients.

Consider chamber music as a special kind of narrative journey.  It is not the hero’s journey that culminates in individual redemption and rebirth but the journey of individual voices conjoined in pursuit of something communal, call it musical truth.  Individual voices assert their authority; they take the lead when called on, enabling other voices to play their supportive roles with greater sensitivity and more perfect ensemble.[1]  The voices interweave and interpenetrate; they invade musical space only to make graceful exits; they weave exquisite filigrees around the melodic inventiveness of others; they learn to yield melodic pride of place, only to reclaim it once again as transformed by other voices.  Out of the dialogue emerges a tapestry whose separate threads merge in single-minded  purpose.  This interpretive solidarity, this playing together, is hemmed in by a composer’s intentions, framed by the compositional traditions and performance practices of a particular time and place.  Absent any single voice, the journey can not be undertaken; there is no tapestry to be woven.

What have we here if not a musical analogue of the kind of narrative competence associated with patient- and relationship-centered medicine?  Interweaving, interpenetrating, entering and exiting, listening to other voices, yielding to other voices, hearing differently because of other voices – aren’t these things at the heart of narrative medicine?

This was the medicine that my father practiced long before scholars decided to study “narrative medicine” as a kind of medicine.  As a violinist, he was especially drawn to Bach, but also to the early and late Romantics, and he could shape a phrase with the same warmth and control with which he helped patients reshape the personal stories they brought to him.  He was a charismatic listener who encouraged his patients to bring him their stories.  But he always listened as their doctor, with the quiet authority to decide on a course of treatment and reassure them all was in hand – because all was in his  mind.  He was, after all, the first violinist, the leader of the quartet.  He knew the score, and he was comfortable taking the lead, both with other chamber players and with his patients.

My father was a man of great modesty and reserve, but his violin always soared with controlled passion.  Just so in medicine:  his personal reserve never diminished the polyphonic textures and expressive sonorities of his medicine, of how he listened to and conversed with his patients and then proceeded to doctor them.

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My father’s model for a life of medicine and music was F. William Sunderman. One of Philadelphia’s premier internists, Sunderman was an accomplished medical researcher at Pennsylvania Hospital.  During the 1930s, he developed new methods for measuring blood cholesterol, glucose, and chloride and invented  the Sunderman Sugar Tube.  During the war, he served as Medical Director of the Manhattan Project, where he developed an antidote for the nickel carbonyl piosoning to which the first atomic bomb assemblers were prone.

Among Philadelphia’s literati, however, Sunderman was best known for integrating medicine and music into a single exemplary life.  The side-by-side entrances of his four-story brownstone at 2210 Delancy Street bore complementary aluminum plaques, one adorned with a caduceus, the other with a lyre and singing bird.  To the former came his patients; to the latter the musicians – eminent scientists and physicians among them – who joined him regularly for chamber music.  Sunderman’s passion for the violin, which in his case was embodied in a collection of exquisite instruments – a Gagliano, a Vuillaume, a Guarnarius – was fast becoming part of Philadelphia’s cultural landscape.

What must Sunderman have thought when, in the fall of 1947, a young war veteran recently graduated from Philadelphia College of Pharmacy wrote him and requested an audience.   The young man, a Jewish immigrant whose parents fled the Russian Pogroms in 1921, knocked on Sunderman’s “musical” door with his GI-liberated Hulinzky in hand.  He announced without fanfare:  “I want to be like you.  My life will be medicine and music.”  And without further ado, my father played for him.  And Sunderman was impressed, both with the young man and with his playing.  And so he endorsed the violinist-pharmacist-serviceman’s application for admission to Philadelphia’s Jefferson Medical College.

Among the area musicians who joined Sunderman for chamber playing on a regular basis was a young cellist and Harvard graduate (class of ’32).  At Harvard, Robert U. Jameson not only played cello but rose to the presidency of the Pierian Sodality, the forerunner of the Harvard-Radcliffe Orchestra.  (In 1941, nine years after Jameson’s graduation, the Orchestra performed his orchestration of  Edward Ballantine’s “Variations on Mary Had a Little Lamb.”)   Now in the real world, Jameson made his living teaching English at The Haverford School on Philadelphia’s Main Line.  An extraordinary teacher who seemed to know his students from the inside out and hence to understand exactly what they needed (viz., how to “coach” them),  Jameson remained a devotee of cello throughout his life.  In the mid-1970s, in failing health but still in the saddle at Haverford, he counted among his students a remarkably gifted young cellist. The two bonded, and the teacher became admiring of his student and warmly supportive of his career aspirations.

The young man played the Saint-Saens Cello Concerto at his teacher’s memorial concert in the spring of 1978, one cellist saluting another, and then moved on to the Curtis Institute, Harvard, and the New York Philharmonic, where he served as Associate Principal Cellist. The cellist, my brother Alan Stepansky, is now Professor of Cello at the Peabody Conservatory and Manhattan School of Music  and a performer and teacher of international stature.

A decade earlier, in the late 1960s, this same Robert U. Jameson took in hand another student who showed  promise as a writer but was in need of the kind of disciplining a chamber-music-playing English teacher could provide. Jameson, a student, like all cellists, of Bach’s Cello Suites, helped him harness luxuriant adolescent prose and understand that restraint is the handmaiden of passion, indeed, that it is the better part of a writer’s valor.  I was that student.  Did Mr. Jameson’s love of cello and chamber playing enter into his understanding of language and his ability to impart, perhaps tacitly, the elements of well-wrought narratives?  Did his instrument help make him the teacher and mentor he was?  Who’s to say it didn’t.


[1] The importance of taking the lead in chamber playing and the manner in which a strong leader enables other players to provide support “with greater sensitivity and more perfect ensemble” – this insight and this wording come from my brother Alan Stepansky.

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