Category Archives: Military Psychiatry

JUST RELEASED: Easing Pain on the Western Front (McFarland, 2020)

Posted on January 14, 2020 | Leave a comment

We are pleased to announce the publication of Easing Pain on the Western Front: American Nurses of the Great War and the Birth of Modern Nursing Practice, the book that has grown out of Paul Stepansky’s popular series of blog essays, “Remembering the Nurses of WWI.”  It has been lauded as “an important contribution to scholarship on nurses and war” (Patricia D’Antonio, Ph.D.) that is simultaneously “the  gripping story of nurses who advanced their profession despite the emotional trauma and physical hardships of combat nursing” (Richard Prior, DNP).  The Preface is presented to the readers of “Medicine, Health, and History” in its entirety.

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Dr. Stepansky is the featured author in the Princeton Alumni Weekly

Listen to him discuss Easing Pain on the Western Front with the editor of the Journal of the American Association of Nurse Practitioners in this special JAANP Podcast

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PREFACE

Studies in the history of nursing have their conventions, and this study of American nursing in World War I does not adhere to them.  It is not an examination of the total experience of military nurses during the Great war.  Excepting only the first chapter, which addresses the American war fever of 1917 and the shared circumstances of the nurses’ enlistment, little attention is paid to aspects of their lives that have engaged other historians.  I do not review the nurses’ families of origin, their formative years, or their reasons for entering the nursing profession.  Similarly, there is relatively little in these pages of the WWI nurses as women, of their role in the history of the women’s movement, or of their personal relationships, romantic or otherwise, with the men with whom they served.

In their place Easing Pain on the Western Front focuses on nursing practice, by which I mean the actual caregiving activities of America’s Great War nurses and their Canadian and British comrades.  These activities comprise the role of nurses in diagnosis, in emergency interventions, in medication decisions, in the use of available technologies, and in devising creative solutions to treatment-resistant and otherwise atypical injuries. And it includes, in these several contexts, nurses’ evolving relationship with the physicians alongside whom they worked.  Among historians of nursing, Christine Hallett stands out for weaving issues of nursing practice into her excellent accounts of the allied nurses of WWI, with a focus on the nurses of Britain and the British Dominions.  Hallett has no counterpart among historians of American nursing, and as a result no effort has been made to gauge the impact of WWI on the trajectory of nurse professionalization in America, both inside and outside the military.

This study begins to address this lacuna from a perspective that stands alongside nursing history.  It  comes from a historian of ideas who works in the history of American medicine.  It is avowedly historicist in nature, grounded in the assumption that nursing practice is not a Platonic universal with a self-evident, objectivist meaning.  Rather this type of practice, like all types of practice, is historically determined, with the line between medical treatment and nursing care becoming especially fluid during times of crisis.  It is intended to supplement the existing literature on WWI nurses, especially the excellent work of Hallett and other informative studies of British, Canadian, and Australian nurses, respectively.  The originality of the work lies in its focus on American nurses, its thematic emphasis on nursing activities, and its argument for the surprisingly modern character of the latter.  Close study of nursing practice, especially in the context of specific battlefield injuries, wound infections, and infectious diseases, yields insights that coalesce into a new appreciation of just how much frontline “doctoring” these nurses actually did.

The case for modern nursing practice in WWI is strengthened by comparative historical inquiry that renders the study, I hope, a more general contribution to the history of military nursing and medicine.  In each of the chapters to follow, I work into the narrative comparative treatment of WWI nursing with nursing in the American Civil War of 1861-1865, the Spanish-American War of 1898, and/or the Anglo-Boer War of 1899-1902.  The gulf that separates Great War nursing from that of wars only two decades earlier, we will see, is wide and deep.  In the concluding chapter, I invert the case for modernity by looking forward from America’s Great War nurses to the American nurses who served in World War II and Vietnam.  If Great War nurses had little in common with the Civil War nurses who preceded them by a half century, they share a great deal, surprisingly, with their successors in Vietnam a half century later.

The focus on nursing practice, then, far from being restrictive in scope, opens to a wide range of issues – medical, cultural, political, and military. Consider, for example, the very notion of healthcare practice, which is determined by a confluence of factors.  Specific theories of disease, rationales for treatment of specific conditions, putative mechanisms of cure, and the grounds for “proving” cure are all central to the historical study of healthcare practice.  Female nursing practice, with the bodily intimacies it entails, also implicates considerations of gender – of what, keeping to the time frame of this study, early-twentieth-century female hands might do to male bodies, and what the males who “owned” these bodies might comfortably permit female hands to do.  Depending on the historical location of nursing practice, issues of social class, nationality, ethnicity, and race may count for as much or more than gender.

By channeling our gaze onto what nurses of the Great War actually did with wounded, suffering, distraught, and dying soldiers, we learn about the many factors that enter into combat nursing at one moment in modern history.  The focus on nursing practice provides a new perspective on the medical advances of the Great War; the role of nurses in making and implementing these advances; the new professional status that accompanied this process; and the American military’s emerging appreciation of trained nurses, indeed of female officers in general.  The focus on nursing practice draws a different picture of the evolution of military personnel policy and the changing social mores and political pressures that accompanied this evolution.

The fate of WWI combat nurses’ role back on the homefront in the aftermath of war is a separate story that I address but briefly in the concluding chapter.  More work should be done on the relationship between military and civilian nursing practice, especially the fate of combat nurses who return to civilian nursing after wartime service.  To keep to the subject matter of this study, the experience of America’s WWI nurses back in civilian hospitals offers an illuminating window into the frustrations and accomplishments of nurses, indeed of professional women in general, in the American workplace in the two decades between the world wars.

For American readers Easing Pain on the Western Front may prove interesting for another reason.  Our increasing reliance on nurses to meet the health care challenges of the twenty-first century, especially in the realm of primary care, underscores the relevance of the unsuspectedly modern Great War nurse providers.  Indeed, they offer a fascinating point of departure for ongoing debates by nurses, physicians, social scientists, and politicians about the scope of practice of nurse practitioners in relation to physicians.  This is because America’s Great War nurses, no less than the nurses of other combatant nations, had to step up during battle “rushes” that overwhelmed their surgeon colleagues.  At such times, and in the weeks and months of intensive care that followed, they became autonomous clinical providers, true forebearers of the nurse practitioners and advanced practice nurses of the present day.  The fact that their professional leap forward occurred in understaffed casualty clearing stations and field hospitals on the Western front during the second decade of the twentieth century lends salience to their accomplishments.

Notwithstanding the many streams of contingency that flow into nursing practice at a given moment in history, I hasten to point out that I am not a historian of gender and that my comments on gender, not to mention ethnicity and race, are sparing.  I invoke them only in the context of specific nursing activities, especially when they were raised by the nurses themselves.  The same may be said of the nurses’ personal lives.  I ignore neither the emotional toll of combat nursing nor the psychological adaptations to which it gave rise.  But here again these issues are addressed primarily in relation to nursing activities, especially the nurses’ perceptions of and reactions to the wounded, ill, and dying they cared for.  I leave to others more comprehensive study of the gender-related, racial, and psychological aspects of American military nursing in World War I and other wars, noting only that the scholarship of Darlene Clark Hine, Margaret Sadowski, and Kara Dixon Vuic has begun to mine this rich vein of nursing history to great effect.

The cohort of nurses at the heart of this study is not limited to American nurses.  They include Canadian and British nurses as well.  In the case of the former, the ground for inclusion is not especially problematic, since many Canadian nurses trained in the United States; indeed, some both trained and worked in the States prior to their wartime service.  Ella Mae Bongard, for example, a Canadian from Picton, Ontario, trained at New York Presbyterian Hospital, practiced in New York for two years after graduating in 1915, and then volunteered with the U.S. Army Nursing Corps.  She ended up at a British hospital in Étretat, where she served with several of her Presbyterian classmates.  The Canadian Alice Isaacson, who served with the Canadian Army Medical Corps, was a naturalized American citizen.  Among other members of the Canadian Nurse Corps,  Mary Catherine Nichols Gunn trained in Ferrisburg VT and initially worked at Nobel Hospital outside Seattle; Annie Main Gee trained at Minneapolis City Hospital with postgraduate studies at New York Polyclinic; and Eleanor Jane McPhedran trained at New York Hospital School of Nursing and worked in the area for three years after graduating.  In all, the training of Canadian nurses and the nursing services they provided were  very much in line with American nursing.

In the case of several prominent British nurses cited throughout the work – Kate Luard, Edith Appleton, Dorothea Crewdson – I am arguably on less certain ground.  British nurses – veiled and addressed as “Sister” –cannot strictly speaking play a role in American nursing practice during the Great War.   I include them nonetheless for several reasons.  The fact is that many British nurses, no less than the Canadians, served abroad for the duration of the war; usually their wartime service extended beyond the Armistice of November 1918 by up to a year.   The duration of their wartime experience makes their diaries and letters, taken en masse, more revelatory of treatment-related issues than those of their American colleagues, whose term of service  was a year or less.  The reflections of Canadian and British nurses on nursing practice on the Western front lend illustrative force to the same battlefield injuries, systemic infections, and psychological traumata encountered by the America nurses as well.

Shared nursing practices were reinforced by considerable interchange among the allied nurses.  Within months of the outbreak of war, American Red Cross (ARC) nurses, all native born and white per ARC requirements, sailed to Europe to lend a hand.  On September 12, 1914, the first 126 departed from New York Harbor on a relief ship officially renamed Red Cross for the duration of the voyage.  A second group of 12 nurses joined three surgeons on a separate vessel destined for Serbia.  Other nurse contingents followed over the next several months, all part of the American Red Cross’s “Mercy Mission.”

Technically ARC nurses were envoys of a neutral nation, and those in the initial group ended up not only in England and France but in Russia, Austro-Hungary, and Germany as well.   In the last the ARC worked in concert with the German Red Cross, and American nurses like Caroline Bauer, stationed in Kosel, Germany in 1915, expressed genuine fondness for the “brave and good” German soldiers under her care.  For the majority of nurses, however, pre-1917 service in British and French hospitals, despite some initial tensions with British supervisors, reinforced ideological and emotional bonds and introduced American nurses to the realities of combat nursing on the Western front.

Even after America’s entry into the war in 1917, American nurses were typically assigned on arrival to British or Canadian hospitals, where they continued their tutelage under senior Canadian and British nursing sisters until returning to their units once their hospitals were ready for them.  Allowing for occasional exceptions, the same medicines (sometimes with different names) were administered, the same procedures performed, and the same technologies employed by the nurses of the allied nations.  To ignore what the Canadian and British nurses have to say about the same issues of nursing practice encountered by the Americans would enervate the study without leading to any refinement of its thesis.

And so, aided by the testimony of Canadian and British nurses,  I am secure in my thesis as it pertains to American nursing and the birth of modern nursing practice.  That being said, I leave it to scholars more knowledgeable than I about Canadian and British nursing history to validate, amend, or reject the thesis in relation to their respective nations.

Finally, it bears noting that in a work about nursing practice that draws on the recollections of a cohort of American, Canadian, and British nurses, each nurse is very much her own person with a personal story to tell.  The memoirs, letters, and diaries that frame this study provide elements of these stories, of how each nurse’s experience interacted with her family history, training, personality, temperament, and capacity for stress management.

In a general way, reactions to the actualities of nursing on the Western front fall along a spectrum of psychological and existential possibilities. At one pole is the affirmation of the combat nursing life provided by Dorothea Crewdson: “I enjoy life here very much indeed. Wonderfully healthy and free.”   At the opposite pole are the mordant reflections of the writer Mary Borden, for whom “The nurse is no longer a woman.  She is dead already, just as I am – really dead, and past resurrection.”  The gamut of reactions, and the richly idiomatic language through which they were expressed, are woven into my narrative at every turn.  I am most concerned, however, with the nurses’ transition from one mindset to another, especially the abruptness with which the life-affirming brio of Crewdson gave way to the horror, demoralization, and depersonalization of Borden. The happy excitement and prideful sense of participation in the war effort with which American nurses set out for the front often dissipated shortly after they arrived and saw the human wreckage that would be the locus of their “nursing.”

Signposts of personal transformation, which I gather together as epiphanies, represent my point of departure in chapter 1.  But in the chapters that follow, these elements of personal biography are subordinate to my focus on nursing practice through a cohort analysis.  Fleshing out the individual stories that undergirded such transformations – the   chronicles of strong, often overpowering emotions that took nurses to the point of physical or nervous collapse – is the stuff of biography and falls beyond the task I have set myself.  It suffices to recall that nurses, no less than the soldiers they cared for, fell victim to what, in the parlance of the war, was termed “shell shock,” even though medical and military personnel steadfastly refused to pin this label on them.  But most of the time the nurses’ descent into the horrific gave rise to adaptive strategies – compartmentalization, dissociation, psychic numbing, black humor – that enabled them to labor on in the service of their soldiers, their “boys.”.

It is with respect to the nurses’ shared ability to bracket their personal stories in the service of a nascent professionalism – a professionalism that segued into medical diagnosis and procedural caregiving far removed from the world of their training and prewar experience – that they reached their full stature.  In so doing, they provide an historical example, deeply moving, of the kind of self-overcoming for which we reserve the term “hero.”

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EASING PAIN ON THE WESTERN FRONT

American Nurses of the Great War and the Birth of Modern Nursing Practice

Paul E. Stepansky

McFarland & Co.     978-1476680019     2020     244pp.     19 photos     $39.95pbk.

Available now from Amazon 

 

 

Copyright © 2020 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

 

 

 

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Posted in General, Medicine in WWI, Nurses in WWI, Nursing

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Remembering the Nurses of WWI (V)

Posted on June 12, 2017 | Leave a comment

“They were very pathetic, these shell shocked boys.”

[The fifth of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917.  Learn more about the nursing response to shell shock in Easing Pain on the Western Front:  American Nurses of the Great War and the Birth of Modern Nursing Practice (McFarland, 2020)].

Every war has mental casualties, but each war has its own way of understanding them.  Each war, that is, has its own nomenclature for what we now term “psychiatric diagnosis.”  To Napoleon’s Surgeon in Chief, Dominique-Jean Larrey, we owe the diagnosis nostalgie   (nostalgia); it characterized soldiers whose homesickness left them depressed and unable to fight.   This was in 1815.  During the American Civil War, nostalgia remained in vogue, but a new term, “irritable heart” (aka  “soldier’s heart” or “Da Costa’s Syndrome”) was coined just after the war to label soldiers whose uncontrollable shivering and trembling had been accompanied by rapid heart beat and difficulty breathing.  During the 10-week Spanish-American War of 1898, soldiers who broke down mentally amid heat, bugs, bullets, and rampant typhoid fever were diagnosed with “tropical weakness.”

And this brings us to World War I, the war that bequeathed the diagnosis of shell shock.  At first, the nurses of WWI were no less baffled by variable expressions of shell shock – most cases of which, it was learned, arose some distance from the exploding shells at the Front – than the doctors.  The term was coined in 1915 by the British physician and psychologist Charles Myers, then part of a volunteer medical unit in France.  Myers immediately realized the term was a misnomer:  he coined it after seeing three soldiers whose similar psychological symptoms followed the concussive impact of artillery shells bursting at close range, only to discover that many men with the same symptoms were no where near exploding shells.   In May, 1917, the American psychiatrist Thomas Salmon, with the approval of the War Department, traveled to England to observe how the British treated their shell shocked soldiers; he returned home convinced that shell shock was a real disorder, not to be taken for malingering, and a disorder that was amenable to psychological treatment.  Salmon was the Medical Director of the National Committee for Mental Hygiene, so his report to the Surgeon General carried weight, and the Army began making arrangements for treating the mental casualties that, he predicted, could flood overseas and stateside hospitals following America’s entry into the war.[1]

Nurses were unconcerned with the animated debate among physicians on the nature of shell shock.  Was it a kind of brain concussion that resulted from the blast force of exploding shells? A physiological response to prolonged fear?  A psychological reaction to the impact of industrial warfare?  A product of nervous shock analogous to  that suffered by victims of railway accidents in the later nineteenth century?   A Freudian-type “war neurosis”  that plugged into earlier traumas  that the soldier had suffered?  They did not care.  Theirs was the everyday world of distressed soldiers, whose florid symptoms overlaid profound anxiety and for whom the reliving of trauma and its aftermath occurred throughout the day.  Theirs was the world, that is, of management and containment.

A shell shocked soldier in a trench during the Somme offensive of September, 1916

The management part could be bemused, good-naturedly patronizing, a tad irritated.  Shell shock victims, after all, made unusual demands on nurses.  The patients were always falling out of bed and otherwise “shaking and stammering and looking depressed and scared.”  Simple tasks like serving meals could be a project, as attested to by the British nursing assistant  Grace Bignold, who, prior to becoming a  VAD in 1915, worked as an orderly at a London convalescent home.  There, she recalled,

One of the things I was told was that when I was serving meals . . . always to put the plate down very carefully in front of them and to let them see me do it.  If you so much as put a plate down in front of them in the ordinary way, when they weren’t looking, the noise made them almost jump through the roof – just the noise of a plate being put on a table with a cloth on it? [2]

Accommodation by the orderlies at mealtime paled alongside the constant burden on ward nurses who had to calm hospitalized shell shock soldiers when exploding shells and overhead bombs rocked the hospital, taking patients back to the Front and causing a recurrence of the anxiety attendant to what they had seen or done or had done to them or to others.  And both, perhaps, paled alongside the burden of nurses in the ambulance trains that transported the shell shocked out of the trenches or off the battlefield.  “It was a horrible thing,” wrote the British VAD and ambulance nurse, Clair Elise Tisdall,

because they sometimes used to get these attacks, rather like epileptic fits in a way.  They became quite unconscious, with violent shivering and shaking, and you had to keep them from banging themselves about too much until they came round again.  The great thing was to keep them from falling off the stretchers, and for that reason we used to take just one at a time in the ambulance. . . . these were the so-called milder cases; we didn’t carry the dangerous ones.  They always tried to keep that away from us and they came in a separate part of the train.”[3]

The latter were the “hopeless mental cases” destined, Tisdall recalled, for “a special place,” i.e., a mental hospital,  in England a “neurasthenic centre.” But how to tell the difference?  The line between “milder” and “severe” cases of shell shock was subjectively drawn and constantly fluctuating; soldiers who arrived in the hospital with some combination of headaches,  tremors, a stutter,  memory loss, and vivid flashback dreams might become psychosomatically blind, deaf or mute or develop paralyzed or spastic limbs after settling into base hospitals and the care of nurses.  In their diaries and letters home, the nurses’ characterizations were not only patronizing but sometimes unkind:  shock patients, often incontinent, were “very pathetic”;  they formed “one of the most pitiful groups” of soldiers.  Dorothea Crewdson referred to them as “dithery shell shocks” and “old doddering shell shocks.” A patient who without warning got out of bed and raced down the hall clad only in his nightshirt was a “dotty poor dear.”  “It is sad to see them,” wrote Edith Appleton.  “They dither like palsied old men, and talk all the time about their mates who were blown to bits, or their mates who were wounded and never brought in.  The whole scene is burnt into their brains and they can’t get rid of the sight of it.”[4]

It is in the containment aspects of their care of the shell shocked that the nurses evinced the same caring acceptance they brought to all their patients.  After, all, shell shocked patients, however they presented, were wounded soldiers, and their suffering was as real and intense as that of comrades with bodily wounds.  The nursing historian Christine Hallett, who writes of the WWI nurses with great sympathy and insight, credits nurses working with the shell shocked with an almost preternatural psychoanalytic sensibility in containing the trauma that underlay their symptoms.  The nurses, she claims, aligned themselves with the patients, however disruptive their outbursts and enactments, since they “sensed that insanity would be a ‘normal’ response for any man who fully realized the deliberateness of the destruction that had been unleashed on him.”  Hence, she continues,

Nurses conspired with their patients to ‘ignore’ or ‘forget’ the reality of warfare until it was safe to remember.  In this way they ameliorated the effect of the ‘psychic splintering’ caused by trauma.  They contained the effects of this defensive fragmentation – the ‘forgetting’ and the ‘denial’ – until patients were able to confront their memories, incorporate them as part of themselves and become ‘whole’ beings again.[5]

I follow Hallett in her insistence that nurses usually ignored the directive not to “spoil” shell shocked patients.  All too often, they let themselves get involved with them at the expense of maintaining professional distance.[6]  

But then the nurses were equally caring and equally prone to personal connection with all their patients, mental or not.  They were not psychotherapists, and the dizzying demands of their long days and nights did not permit empathic engagement in the psychoanalytic sense, beyond the all-too-human  realization that the shell shocked had experienced something so horrible as to require a gentleness, a lightness of touch, a willingness to accept strange adaptive defenses that, with the right kind of nursing,  might peel away slowly over time.  Here, for example, is one of Hallett’s examples of “emotional containment” on the part of  the Australian army nurse Elsie Steadman:

It was very interesting work, some of course could not move, others could not speak, some had lost their memory, and did not even know their own names, others again had very bad jerks and twitching.  Very careful handling these poor lads needed, for supposing a man was just finding his voice, to be spoken to in any way that was not gentle and quiet the man ‘was done,’ and you would have to start all over again to teach him to talk, the same things applied to walking, they must be allowed to take their time.”[7]

This sensitivity, this “very careful handling” of the shell shocked, was no different than the sensitivity of the mealtime orderlies, who knew to “put the plate down very carefully in front of them,” always making sure that the shell shocked saw them do it.  And of course there were accommodations out of the ordinary, a remarkable example of which comes from Julia Stimson, the American chief nurse of British Base Hospital 21 (and amateur violinist). Writing to her parents in late November, 1917, she related “an interesting little incident” that began when a patient knocked on her door and asked for the Matron:

He was so wobbly he almost had to lean up against the wall.  “Somebody told me,” he said, “that you had a violin.  I am a professional violinist and I have not touched a violin for five months, and today I couldn’t stand it any longer, so I got up out of bed to come and find you.”  I made him come in and sit down.  As it happened I had a new violin and bow, which had been bound for our embryo orchestra, here in my office.  The violin was not tuned up, but that didn’t matter.  The man had it in shape in no time and then he began to play and how he could play!  We let him take the violin down to his tent, and later sent him some of my music.  He was a shell shock, and all the evening and the next few days until he was sent to England he played to rapt audiences of fellow patients.[8]

With the shell shocked, the therapeutic gift of the WWI nurses resided less in their ability to empathize than in their acceptance that their patients had experienced horrors that could not be empathized with.  Their duty, their calling, was simply to stay with these soldiers in an accepting manner that coaxed them toward commonality among the wounded, the sense that their symptoms and the underlying terror were not only understandable but unexceptional and well within the realm of nursing care.  In this sense – in the sense of a daily willingness to be with these soldiers in all their bodily dysfunction, mental confusion, and florid symptomatic displays – the nurses strove to normalize shell shock for the shell shocked. After all, the shell shocked, however dithery, shaking, and stammering, were depressed and scared “only at times.”  Otherwise, continued Dorothea Crewdson, “they are very cheery and willing.”  Mary Stollard, a British nurse working  with shell shocked soldiers at a military hospital in Leeds, noted that many of the boys were very sensitive to being incontinent.

They’d say, ‘‘I’m  terribly sorry about it, Sister, it’s shaken me all over and I can’t control it.  Just imagine, to wet the bed at my age!”  I’d say, “We’ll see to that.  Don’t worry about it.”  I used to give them a bedpan in the locker beside them and keep it as quiet as possible.  Poor fellows, they were so embarrassed – especially the better-class men.”[9]

But such embarrassment was a relic of civilian life.  It had no place among battle-hardened nurses who coped daily with the sensory overload of trench warfare:  the overpowering stench of gangrenous infections and decaying flesh; the sight of mutilated soldiers without faces or portions of torso, not to mention missing arms and legs; the screams of gassed soldiers, blind and on fire and dying in unspeakable pain.  Alongside such things, how off-putting could incontinence be?  The fact is that shell shocked soldiers, no less than the nurses themselves, were warriors. Warriors are wounded and scarred in many ways; nurses themselves fell victim to shell shock, even if they were not officially diagnosed as such.[10]   Knowing full well that shell shocked soldiers declared physically unfit and shipped back home were often subject to stigma and humiliation,  Ellen La Motte offered this dismal prognosis for one who had lost the ability to walk and could no longer serve the nation:  “For many months he had faced death under the guns, a glorious death.  Now he was to face death in another form.  Not glorious, shameful.”[11]

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[1] Earl D. Bond, Thomas W. Salmon – Psychiatrist  (NY: Norton, 1950), 83-84.

[2] Julia C. Stimson, Finding Themselves:  The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 41; Dorothea Crewdson, Dorothea’s War:  A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013), loc 4383; Grace Bignold, in Lyn MacDonald, The Roses of No Man’s Land (London: Penguin, 1993), 233.

[3]  Claire Elise Tisdall, in MacDonald, Roses of No Man’s Land, 233-34.

[4] Mary Stollard, in MacDonald, Roses of No Man’s Land, 231-32; Stimson, Finding Themselves, 41; Crewdson, Dorothea’s War, loc 967; Edith Appleton, A Nurse at the Front:  The First World War Diaries, ed. R. Cowen (London:  Simon & Schuster UK, 2012), 184.

[5] Christine Hallett, Containing Trauma:  Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 163.

[6] Hallett, Containing Trauma, 165, 177.

[7] Hallett, Containing Trauma, 172-73.

[8] Stimson, Finding Themselves, 163.

[9] Crewdson, Dorothea’s War,  loc 4383; Stollard, in MacDonald, Roses of No Man’s Land, 232.

[10] E.g., Crewdson, Dorothea’s War, loc 4914; In “Blind,” Mary Borden writes of herself as “jerk[ing] like a machine out of order.  I was away now, and I seemed to be breaking to pieces.”  She was sent home as “tired.”  Mary Borden, The Forbidden Zone (London: Hesperus, 2008[1929], 103).  On the military’s unwillingness to diagnose women as “shell shocked,” see Hannah Groch-Begley, “The Forgotten Female Shell-Shock Victims of World War I,” The Atlantic, September 8, 2014 (https://www.theatlantic.com/health/archive/2014/09/world-war-ones-forgotten-female-shell-shock-victims/378995).

[11] Ellen N. La Motte, The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse (NY: Putnam’s, 1916), 239.

Copyright © 2017 by Paul E. Stepansky.  All rights reserved.  The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.

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Posted in Medicine in WWI, Military Psychiatry, Nurses in WWI, Nursing Care, War & Medicine

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The Paradox of Generalist Specialists

Posted on February 4, 2013 | Leave a comment

General practitioners of medicine (GPs), the medical heroes of World War II, returned home only to find their medical standing at their local hospitals in jeopardy.  Specialization made great inroads during the war years, and, while the GPs were fighting the war in Europe, many hospitals reclassified their staff physicians on the basis of specialist qualifications.  GPs of course were low men on the totem pole, and some found that the very hospitals where they had worked before the war had rescinded their surgical privileges after the war.  Stanley R. Truman, the first Secretary of the American Academy of General Practice and chronicler of its founding, recalled this very situation at his own Merritt Hospital in Oakland, CA.  “Some of these men had gone away with major surgical privileges,” he later recalled, “and had been assigned leading surgical responsibilities here and overseas.  They were furious when they came home and found themselves in ‘Class A’ [the lowest rung of the hospital hierarchy, in which surgery could only be performed after consultation and under supervision].”  One day in late 1945, Truman continued,

I met Harold Maloney who had just come back.  He was one of our leading general practitioners; a fine doctor and surgeon; a member of the American College of Surgeons and in ‘Class A.’ We had previously talked about an organization of general practitioners; and this day, in talking the situation over again, we agreed that an organization was urgent.[1]

And so the GPs organized, first into the General Practitioners Association of Truman’s Alameda County; then in 1945 into the Section on General Practice of the American Medical Association; and finally in 1947 into the American Academy of General Practice (AAGP).  The organizers and officers of the AAGP, who assumed the burden of promoting the new organization and encouraging the formation of local chapters, made no bones about the reason for its existence .  It was not about “family practice,” “comprehensive care,” “total patient care,” or any of the other buzzwords that were invoked in the discussions two decades later that led to the creation of the American Board of Family Practice in 1969.  It was about power pure and simple, and power in postwar America meant the power to treat one’s patients in the hospital, including patients who required operative obstetrics and major surgery.

Returning GPs, who, as General Medical Officers, had met wartime needs at both ends of the specialty spectrum – in psychiatry and in surgery – were aghast at rumors that certain stateside hospitals – perhaps their own hospitals – planned to limit their staffs to board-certified medical specialists by the early 50s. Was this their reward for exemplary service to the nation?  “Since the second World War,” intoned the AAGP’s first President, Paul Davis, in 1948, the GP “has been discriminated against in many cases, and had his professional standards encroached upon.”  In 1953, two of New York’s leading GPs recollected:  “It was as if the hospitals were about to put up signs reading: ‘If you’re a general practitioner, keep out!”  A few years later, Eric Royston, another prominent AAGP booster, recalled the postwar feeling among GPs of being discriminated against in their medical associations “and being pushed to the periphery in the metropolitan hospitals.”[2] The AAGP would come to the rescue; it would have the strength of numbers,[3] which meant it would have the power. The AAGP’s resolve to keep GPs in the hospitals and put scalpels back in their hands was baldly stated in Article II of the its constitution, which set forth this organizational objective:  “To preserve the right of the general practitioner to engage in medical and surgical procedures for which he is qualified by training and experience.”[4]

But all did not go as planned.  Although the AAGP stabilized the GP’s hospital status as it existed before the war, it could not protect GPs from the continuing development of specialty medicine, which increasingly took place in hospitals and entailed ever more sophisticated procedures and interventions.  Specialty encroachment of GP hospital privileges might be slowed but never halted.  And along with the organizational support came the stigma, which is exactly what the AAGP sought to prevent.  In the late 40s, many GP-surgeons resisted joining the AAGP lest — publicly identified as GPs – they have their surgical privileges rescinded.  On the other hand, the few GP residency programs that proved successful in the early 60s, mostly in California, were those that taught surgery and permitted GP residents to perform major operations.[5]  It was all about surgery, all about procedures, all about treatment-related prerogatives within the hospital.

Of course, the AAGP could not prevail, given the great impetus to specialization provided by the war.  When, in the mid-1960s, efforts to upgrade the status of the generalist centered around creation of a new residency-based specialty, “family practice,” it was no longer a matter of surgical privileges within the hospital.  No, family practice would be a new and different kind of specialty, one less concerned with procedures and surgeries than with holistic, patient-centered, intergenerational caregiving.  The retreat from proceduralism was codified in the “Core Content” of family practice adopted by the AAGP in 1966.  The family practitioner (FP) of the future, it held, would assume “comprehensive and continuing responsibility” for his or her patients.  This meant that family practice would be a  “horizontal specialty” that cut across the other specialties.  It would fall back on “function” rather than a “body of knowledge.”[6]

What was lost in the new rhetoric of patient-centered caregiving was the very thing that mattered so much to the AAGP two decades earlier:  safeguarding the GP’s prerogative to perform those procedures and interventions that fell within the domain of the practicing (as opposed to the caring) generalist.  The proponents of family practice could no longer hope to wrest control of a piece of the medical pie, so they elaborated a new – and, they fervently hoped, specialized – gloss on the pie in its entirety.  This amounted to proposing a “sort of a focus”[7] for the residency-trained FP of the future.  What FP proponents and educators failed to do was delineate in a conventional manner the procedural correlates of the FP’s “focus” – the things that all FPs would be trained to do that qualified as specialist interventions, not just attitudinal correlates of caregiving that meshed with their person-centered ideology.

The question-begging nature of early definitions of family practice is nowhere more evident than in the matter of surgery.  By the mid-60s, the founders of family practice realized full well that the American College of Surgeons would never cede residency-trained family practitioners the prerogative to perform major operations in the hospital. Furthermore, adding insult to injury, the AAGP was beset with a schism within its own ranks:  there were GPs who did considerable surgery (including operative obstetrics) and GPs who did not.  The former believed family practice should include a strong surgical component; the latter did not.  The former were concerned about the exclusion of surgery from “modern” family practice, and for this reason they opposed the development of a family practice specialty board through the early 60s.  The pragmatic (non)solution to this quandary was simply to leave the issue open.  The AAGP’s vision of the new family practice specialist, as spelled out in its “Core Content” position paper of 1966, assigned family practitioners the nebulous domain of “applicable surgery,” meaning that “the physician in family practice should be trained to do the types and kinds of surgery he would be required to perform after graduation.”

There is irony in this nebulous manifesto:  the very effort to transform old-style general practice into specialized family practice hinged on a willingness to fall back on a pre-1930s notion of specialization in which generalists would somehow know, in advance of practice, what kinds of techniques they would need to master for their future work.  They would then “pick up” these techniques during residency or after residency in the world of everyday practice and occasional postgraduate courses.  Family practice, in these mid-60s deliberations, increasingly looked like a specialty that was not only “different,” but antithetical to the very meaning of specialization.  That is, if family practice is a medical specialty of any kind, then all FP residents should receive common training in a range of diagnostic and treatment procedures that, in their totality, add up to specialist interventional care.  The willingness to localize procedural skills, to leave it to individual practitioners and/or training programs to determine which skills would be “appropriate” to practice, was a nod to the surgical specialists, whose advanced training and control of hospitals was shored up by the postwar climate of opinion.  But it had the paradoxical effect of marginalizing the family practitioner out of the gate:  once you begin localizing the procedural, hands-on component of any specialty, medical or otherwise, you risk gutting the specialty, cutting away the shared procedural content that coalesces into expert knowledge and sustains a common professional identity.  What kind of specialty leaves it to the individual to fill in the procedural content of the specialty as he or she proceeds through training and practice?

Here we have a central dilemma of family medicine.  I invoke it here in support of the need for a new kind of generalist physician who is procedurally empowered in the manner of GPs of the 1940s and 50s.  We need to oscillate back to generalists who can do many things and away from generalist physicians who hypothetically know their patients “better” but are increasingly content to “coordinate” their care.  The family practice movement failed because it sought the impossible: to create a new kind of specialty that would not delimit expertise in treatment-specific ways.

The family practitioner of the 1970s was to be an interpersonally embedded, empathically attuned, total-patient provider.  He or she was to provide comprehensive care that was intergenerational, mind-body care.  Proponents of the movement spent years debating what “comprehensive care” meant, and ultimately had to beg the question.  The result was a medical specialty that, until recently, lacked consensually agreed on procedural requirements.  The semantically strained, even oxymoronic, vision of a non-specialty specialty, a specialty that rejected specialist values, was an amalgam of 1960s counterculture, the social sciences, and a dash of psychoanalytic object relations theory (per Michael Balint), all abetted by the dearth of “personal physicians” and the emergence in the 1970s of the patient rights movement.   Family practice was of its time – it was entirely admirable and terribly ill-fated.  This is why only eight percent of non-osteopathic medical students now choose to “specialize” in it.[8] It is also why some top-tier medical schools — Harvard,  Yale, Johns Hopkins, Columbia, and Cornell, among them —  do not even have departments of family medicine.

If we are to address the primary care crisis within rural America, we need a new kind of doctor – call them specialists in procedural rural medicine (PRM) or rural care proceduralists (RCPs) – who can actually take care of people in rural settings where specialists are sparse.  Such physicians will not do many things, certainly not the kinds of surgeries that GP-surgeons of the postwar era felt within their province. But they will be trained to do much more than the majority of contemporary family physicians.  Their connection with their patients will rely less on prescribing and coordinating than on what W. R. Houston, in his justly celebrated address to the American College of Physicians of 1937, termed “the line of procedure.”[9]  We need primary care physicians who do things to their patients’ bodies.  Such physicians will “touch” their patients in the dual sense of activating an inborn biological pleasure (contact touch) and allowing such pleasure, through symbolic elaboration, to become a touchstone of a trusting doctor-patient relationship.[10]  A renewal of procedural medicine will not make indifferent caregivers caring, but it will fortify in the realm of action what Houston termed the “dynamic power” of the doctor-patient relationship.  It will make it easier for caring doctors to doctor.

In the next essay in this series, we will look further at procedural rural medicine and how it would differ from family medicine as it currently exists.

[1] S. A. Truman, The History of the Founding of the American Academy of General Practice (St. Louis: Green, 1969), p. 16.

[2] P. A. Davis, “The American Academy of General Practice,” Southern Med. J., 41:651-55, 1948, at p. 654; W. C. Allen & S. A. Garlan, “Educational motivation in the field of general practice,” NY State J. Med., 53:1243-1245, 1953, at p. 1243; E. A. Royston, “The American Academy of General Practice:  its origin, objectives, growth and outlook,” S. Afr. Med., J., 30:298-99, 1956.

[3] The AAGP had well over 2,000 members by the end of 1947, the year of its founding.  By 1968, membership had grown to 30,000.  Truman, op cit., pp. 54, 60.

[4] N.A., Family Practice: Creation of a Specialty (American Academy of Family Physicians, 1980), p. 34; Truman, op cit., p. 43.

[5] Family Practice: Creation of a Specialty, op. cit., pp. 12, 20.

[6] Family Practice: Creation of a Specialty, op. cit., pp. 37-38.

[7] Family Practice: Creation of a Specialty, op. cit., p. 42.

[8] W. S. Biggs, et al., “Entry of US medical school graduates into family medicine residencies: 2011-2012,” Fam. Med., 44:620-626, 2012.

[9] W. R. Houston, “The doctor himself as a therapeutic agent,” Ann. Int. Med., 11:1416-1425, 1938.

[10] See, for example, N. S. Lehrman, “Pleasure heals: the role of social pleasure—love in its broadest sense—in medical practice,” Arch . Intern. Med., 1993;153:929–934.  Contemporary physicians writing about primary care have little to say about the salience of the laying on of hands – even when mediated by instrumentation – as a component of care-giving that mobilizes patient trust.  But there is much to be gleaned from contiguous literature, e.g., G. Pohl, et al., “’Laying on of hands’ improves well-being in patients with advanced cancer,” Support Care Cancer, 15:143-151, 2007; S. Jain, et al., “Healing touch with guided imagery for PTSD in returning active duty military: a randomized controlled trial,” Mil. Med., 177:1015-1021, 2012;  and T. Jones & L. Glover, “Exploring the psychological processes underlying touch: lessons from the Alexander technique,” Clin. Psychol. Psychother., Nov., 2012 (Epub ahead of print).

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

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Posted in Family Doctors, Then & Now, General Practice, Medicine in WWII, Procedural Rural Medicine

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My Father’s Empathy

Posted on June 16, 2012 | Leave a comment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Posted in Empathy, General Practice, Medical Education, Medicine in WWII, Premed Education

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A Musical Offering

Posted on February 24, 2012 | Leave a comment

“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.

_________________

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.

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Posted in Doctor-Patient Communication, General, Medicine and Music, Medicine in WWII, Narrative Medicine

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An Irony of War

Posted on February 11, 2012 | Leave a comment

“There are two groups of people in warfare – those organized to inflict and those organized to repair wounds – and there is little doubt but that in all wars, and in this one in particular, the former have been better prepared for their jobs” (Milit. Surg., 38:601, 1916).  So observed Harvey Cushing, the founder of modern neurosurgery, a year before America’s entry into World War I.  Cushing’s judgment is just, and yet throughout history “those organized to repair wounds” have risen to the exigencies  of the war at hand.  In point of fact, warfare has spurred physicians, surgeons, and researchers to major, sometimes spectacular, advances, and their scientific and clinical victories are bequeathed  to civilian populations that inherit the peace.  Out of human destructiveness emerge potent new strategies of protection, remediation, and self-preservation.  Call it an irony of war.

Nor are these medical and surgical gifts limited to the era of modern warfare.  The French army surgeon Jean Louis Petit invented the screw tourniquet in 1718; it made possible leg amputation above the knee.  The Napoleonic Wars of the early nineteenth century brought us the first field hospitals along with battlefield nursing and ambulances.  The latter were of course horse-drawn affairs, but they were exceedingly fast and maneuverable and were termed “flying ambulances.”  The principle of triage — treating the wounded, regardless of rank, according to severity of injury and urgency of need – is not a product of twentieth-century disasters.  It was devised by Dominique Jean Larrey, Napoleon’s surgeon-in-chief from 1797 to 1815.

The American Civil War witnessed the further development of field hospitals and the acceptance, often grudging, especially among southern surgeons, of female nurses tending to savaged male bodies.  Hospital-based training programs for nurses were a product of wartime experience.  Civil War surgeons themselves broached the idea shortly after the peace, and the first such programs opened  in New York, Boston, and New Haven hospitals in 1873.  The dawning appreciation of the relationship between sanitation and prevention of infection, which would blossom into the “sanitary science” of the 1870s and 1880s, was another Civil War legacy.

And then there were the advances, surgical and technological, in amputation.  They included the use of the flexible chain saw to spare nerves and muscles and even, in many cases of comminuted fracture, to avoid amputation entirely.  The development of more or less modern vascular ligation – developed on the battlefield to tie off major arteries extending from the stumps of severed limbs – is another achievement of Civil War surgeons.  Actually, they rediscovered ligation, since the French military surgeon Amboise Paré employed it following battlefield amputation in the mid-sixteenth century, and he in turn was reviving a practice employed in the Alexandrian Era of the fourth century B.C.

In 1900 Karl Landsteiner, a Viennese pathologist and immunologist, first described the ABO system of blood groups, founding the field of immunohematology.  As a result, World War I gave us blood banks that made possible blood transfusions among wounded soldiers in the Army Medical Corps in France.  The First World War also pushed medicine further along the path to modern wound management, including the treatment of cellulitic wound infections, i.e., bacterial skin infections that followed soft tissue trauma.  Battlefield surgeons were quick to appreciate the need for thorough wound debridement and delayed closure in treating contaminated war wounds.  The prevalence of central nervous system injuries – a tragic byproduct of trench warfare in which soldiers’ heads peered anxiously above the parapets  – led to “profound insights into central nervous system form and function.” The British neurologist Gordon Holmes provided elaborate descriptions of spinal transections (crosswise fractures) for every segment of the spinal cord, whereas Cushing, performing eight neurosurgeries a day, “rose to the challenge of refining the treatment of survivors of penetrating head wounds” (Arch. Neurol., 51:712, 1994).  His work from 1917 “lives today” (ANZ J. Surg., 74:75, 2004).

No less momentous was the development of reconstructive surgery by inventive surgeons (led by the New Zealand ENT surgeon Harold Gillies) and dentists (led by the French-American Charles Valadier) unwilling to accept the gross disfigurement of downed pilots who crawled away from smoking wreckages with their lives, but not their faces, intact.  A signal achievement of wartime experience with burn and gunshot victims was Gillies’s Plastic Surgery of the Face of 1920; another was the founding of the American Association of Plastic Surgeons a year later.  After the war, be it noted, the pioneering reconstructive surgeons refused to place their techniques at the disposal of healthy women (and less frequently healthy men) desirous of facial enhancement; reconstructive facial surgery went into short-lived hibernation.  One reason reconstructive surgeons morphed into cosmetic surgeons was the psychiatrization of facial imperfection via Freudian and especially Adlerian notions of the “inferiority complex,” with its allegedly life-deforming ramifications.  So nose jobs became all the rage in the 1930s, to be joined by facelifts in the postwar 40s. (Elizabeth Haiken’s book Venus Envy: A History of Cosmetic Surgery [1997] is illuminating on all these issues.)

The advances of World War II are legion.  Among the most significant was the development or significant improvement of 10 of the 28 vaccine-preventable diseases identified in the twentieth century (J. Pub. Health Pol., 27:38, 2006);  new vaccines for influenza, pneumococcal pneumonia, and plague were among them.   There were also new treatments for malaria and the mass production of penicillin in time for D-Day.  It was during WWII that American scientists learned to separate blood plasma into its constituents (albumin, globulins, and clotting factors), an essential advance in the treatment of shock and control of bleeding.

No less staggering were the surgical advances that occurred during the war. Hugh Cairns, Cushing’s favorite student, developed techniques for the repair of the skull base and laid the foundation of modern craniofacial surgery by bringing together neurosurgeons, plastic surgeons, and ophthalmic surgeons in mobile units referred to as “the trinity.”   There were also major advances in fracture and wound care along with the development of hand surgery as a surgical specialty.   Wartime treatment experience with extreme stress, battlefield trauma, and somatization (then termed, in Freudian parlance, “conversion reactions”) paved the way for the blossoming of psychosomatic medicine in the 1950s and 1960s.

The drum roll hardly ends with World War II.  Korea gave us the first air ambulance service.  Vietnam gave us Huey helicopters for evacuation of wounded soldiers.  (Now all trauma centers have heliports.)  Prior to evacuation, these soldiers received advanced, often life-saving, care from medical corpsmen who opened surgical airways and performed thoracic needle decompressions and shock resuscitation; thus was born our modern system of prehospital emergency care by onsite EMTs and paramedics.  When these corpsmen returned to the States, they formed the original candidate pool for Physician Assistant training programs, the first of which opened its doors at Duke University Medical Center in 1965.  Vietnam also gave us major advances in vascular surgery, recorded for surgical posterity in the “Vietnam Vascular Registry,” a database with records of over 8000 vascular wound cases contributed by over 600 battlefield surgeons.

The medical and surgical yield of recent and ongoing wars in the Persian Gulf will be recorded in years to come.  Already, these wars have provided two advances for which all may give thanks:  portable intensive care units (“Life Support for Trauma and Transport”) and Hem-Con bandages.  The latter, made from extract of shrimp cells, stop severe bleeding instantaneously.

Now, of course, with another century of war under our belt and the ability to play computer-assisted war games, we are better able to envision the horrific possibilities of wars yet to come.  In the years leading up to World War I, American surgeons – even those, like Harvey Cushing, who braced themselves for war – had no idea of the human wreckage they would encounter in French field hospitals.  Their working knowledge of war wounds relied on the Boer War (1899-1900), a distinctly nineteenth-century affair, militarily speaking, fought in the desert of South Africa, not in trenches in the overly fertilized, bacteria-saturated soil of France.  Now military planners can turn to databases that gather together the medical-surgical lessons of two World Wars, Korea, Vietnam, Iraq, Afghanistan, and any number of regional conflicts.

Military simulations have already been broadened to include political and social factors.  But military planners should also be alert to possibilities of mutilation, disfigurement, multiple-organ damage, and drug-resistant infection only dimly imagined.  Perhaps they can broaden their simulations to include the medical and surgical contingencies of future wars and get bench scientists, clinical researchers, and surgeons to work on them right away.  Lucky us.

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

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Posted in Civil War Medicine, Medicine in Vietnam, Medicine in WWI, Medicine in WWII, War & Medicine

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Primary Care/Primarily Caring (IV)

Posted on December 8, 2011 | 1 comment

If it is little known in medical circles that World War II “made” American psychiatry, it is even less well known that the war made psychiatry an integral part of general medicine in the postwar decades.  Under the leadership of the psychoanalyst (and as of the war, Brigadier General) William Menninger, Director of Neuropsychiatry in the Office of the Surgeon General, psychoanalytic psychiatry guided the armed forces in tending to soldiers who succumbed to combat fatigue, aka war neuroses, and getting some 60% of them back to their units in record time.   But it did so less because of the relatively small number of trained psychiatrists available to the armed forces than through the efforts of the General Medical Officers (GMOs), the psychiatric foot soldiers of the war.  These GPs, with at most three months of psychiatric training under military auspices, made up 1,600 of the Army’s  2,400-member neuropsychiatry service (Am. J. Psychiatry., 103:580, 1946).

The GPs carried the psychiatric load, and by all accounts they did a remarkable job.  Of course, it was the psychoanalytic brass – William and Karl Menninger, Roy Grinker, John Appel, Henry Brosin, Franklin Ebaugh, and others – who wrote the papers and books celebrating psychiatry’s service to the nation at war.  But they all knew that the GPs were the real heroes.  John Milne Murray, the Army Air Force’s chief neuropsychiatrist, lauded them as the “junior psychiatrists” whose training had been entirely “on the job” and whose ranks were destined to swell under the VA program of postwar psychiatric care (Am. J. Psychiatry, 103:594, 1947).

The splendid work of the GMOs encouraged expectations that they would help shoulder the nation’s psychiatric burden after the war. The psychiatrist-psychoanalyst Roy Grinker, coauthor with John Spiegel of the war’s enduring  contribution to military psychiatry, Men Under Stress (1945), was under no illusion about the ability of trained psychiatrists to cope with the influx of returning GIs, a great many “angry, regressed, anxiety-ridden, dependent men” among them (Men Under Stress, p. 450).  “We shall never have enough psychiatrists to treat all the psychosomatic problems,” he remarked in 1946, when the American Psychiatric Association boasted all of 4,000 members.  And he continued:  “Until sufficient psychiatrists are produced and more internists and practitioners make time available for the treatment of psychosomatic syndromes, we must use heroic shortcuts in therapy which can be applied by all medical men with little special training” (Psychosom. Med., 9:100-101, 1947).

Grinker was seconded by none other than William Menninger, who remarked after the war that “the majority of minor psychiatry will be practiced by the general physician and the specialists in other fields” (Am. J. Psychiatry, 103:584, 1947).  As to the ability of stateside GPs to manage the “neurotic” veterans, Lauren Smith, Psychiatrist-in-Chief to the Institute of Pennsylvania Hospital prior to assuming his wartime duties, offered a vote of confidence two years earlier.  The majority of returning veterans would “present” with psychoneuroses rather than major psychiatric illness, and most of them “can be treated successfully by the physician in general practice if he is practical in being sympathetic and understanding, especially if his knowledge of psychiatric concepts is improved and formalized by even a minimum of reading in today’s psychiatric literature”  (JAMA, 129:192, 1945).

These appraisals, enlarged by the Freudian sensibility that saturated popular American culture in the postwar years, led to the psychiatrization of American general practice in the 1950s and 60s.  Just as the GMOs had been the foot soldiers in the campaign to manage combat stress, so GPs of the postwar years were expected to lead the charge against the ever growing number of “functional illnesses” presented by their patients (JAMA, 152:1192, 1953; JAMA, 156:585, 1954).  Surely these patients were not all destined for the analyst’s couch.  And in truth they were usually better off in the hands of their GPs, a point underscored by Robert Needles in his address to the AMA’s Section on General Practice in June of 1954.  When it came to functional and nervous illnesses, Needles lectured, “The careful physician, using time, tact, and technical aids, and teaching the patient the signs and meanings of his symptoms, probably does the most satisfactory job” (JAMA, 156:586, 1954).

Many generalists of the time, my father, William Stepansky, among them, practiced psychiatry.  Indeed they viewed psychiatry, which in the late 40s, 50s, and 60s typically meant psychoanalytically informed psychotherapy, as intrinsic to their work.  My father counseled patients from the time he set out his shingle in 1953.  Well-read in the psychiatric literature of his time and additionally interested in psychopharmacology, he supplemented medical school and internship with basic and advanced-level graduate courses on psychodynamics in medical practice.  Appointed staff research clinician at McNeal Laboratories in 1959, he conducted and published  (Cur. Ther. Res. Clin. Exp., 2:144, 1960) clinical research on McNeal’s valmethamide, an early anti-anxiety agent.  Beginning in the 1960s, he attended case conferences at Norristown State Hospital (in exchange for which he gave his services, gratis, as a medical consultant).  And he participated in clinical drug trials as a member of the Psychopharmacology Research Unit of the University of Pennsylvania’s Department of Psychiatry, sharing authorship of several publications that came out of the unit.  In The Last Family Doctor, my tribute to him and his cohort of postwar GPs, I wrote:

“The constraints of my father’s practice make it impossible for him to provide more than supportive care, but it is expert support framed by deep psychodynamic understanding and no less valuable to his patients owing to the relative brevity of 30-minute ‘double’ sessions.  Saturday mornings and early afternoons, when his patients are not at work, are especially reserved for psychotherapy.  Often, as well , the last appointment on weekday evenings is given to a patient who needs to talk to him.  He counsels many married couples having difficulties.  Sometimes he sees the husband and wife individually; sometimes he seems them together in couples therapy.  He counsels the occasional alcoholic who comes to him.  He is there for whoever seeks his counsel, and a considerable amount of his counseling, I learn from [his nurse] Connie Fretz, is provided gratis.”

To be sure, this was family medicine of a different era.  Today primary care physicians (PCPs) lack the motivation, not to mention the time, to become frontline psychotherapists.  Nor would their credentialing organizations (or their accountants) look kindly on scheduling double-sessions for office psychotherapy and then billing the patient for a simple office visit.  The time constraints under which PCPs typically operate, the pressing need to maintain practice “flow” in a climate of regulation, third-party mediation, and bureaucratic excrescences of all sorts – these things make it more and more difficult for physicians to summon the patience to take in, much less to co-construct and/or psychotherapeutically reconfigure, their patients’ illness narratives.

But this is largely beside the point.  Contemporary primary care medicine, in lockstep with psychiatry, has veered away from psychodynamically informed history-taking and office psychotherapy altogether.  For PCPs and nonanalytic psychiatrists alike – and certainly there are exceptions – the postwar generation’s mandate to practice “minor psychiatry,” which included an array of supportive, psychoeducative, and psychodynamic interventions, has effectively shrunk to the simple act of prescribing psychotropic medication.

At most, PCPs may aspire to become, in the words of Howard Brody, “narrative physicians” able to empathize with their patients and embrace a “compassionate vulnerability” toward their suffering.  But even this has become a difficult feat.  Brody, a family physician and bioethicist, remarks that respectful attentiveness to the patient’s own story or “illness narrative” represents a sincere attempt “to develop over time into a certain sort of person – a healing sort of person – for whom the primary focus of attention is outward, toward the experience and suffering of the patient, and not inward, toward the physician’s own preconceived agenda” (Lit. & Med., 13:88, 1994; my emphasis).  The attempt is no less praiseworthy than the goal.  But where, pray tell, does the time come from?  The problem, or better, the problematic, has to do with the driven structure of contemporary primary care, which makes it harder and harder for physicians to enter into a world of open-ended storytelling that over time provides entry to the patient’s psychological and psychosocial worlds.

Whether or not most PCPs even want to know their patients in psychosocially (much less psychodynamically) salient ways is an open question.  Back in the early 90s, primary care educators recommended special training in “psychosocial skills” in an effort to remedy the disinclination of primary care residents to address the psychosocial aspects of medical care.  Survey research of the time showed that most residents not only devalued psychosocial care, but also doubted their competence to provide it (J. Gen. Int. Med., 7:26, 1992; Acad. Med., 69:48, 1994).

Perhaps things have improved a bit since then with the infusion of courses in the medical humanities into some medical school curricula and focal training in “patient and relationship-centered medicine” in certain residency programs.   But if narrative listening and relationship-centered practice are to be more than academic exercises, they must be undergirded by a clinical identity in which relational knowing is constitutive, not superadded in the manner of an elective.  Psychodynamic psychiatry was such a constituent in the general medicine that emerged after World War II.  If it has become largely irrelevant to contemporary primary care, what can take its place?  Are there other pathways through which PCPs, even within the structural constraints of contemporary practice, may enter into their patients’ stories?

Copyright © 2011 by Paul E. Stepansky.  All rights reserved.

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Posted in Family Doctors, Then & Now, General Practice, Medicine in WWII, Primary Care, Psychiatry in Medicine, War & Medicine

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