Category Archives: Medical Humanities

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.

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.