Category Archives: Narrative Medicine

The Hunt For Caring Med Students

The MCATs, new and improved, will save us!  The overhauled medical school admissions test, which was approved by the American Association of Medical Colleges last February and will take effect in 2015, will devote almost half its questions to the social sciences and critical reasoning, with the latter including reading passages addressing cross-cultural issues and medical ethics.  According to Darrell G. Kirch, President of the AAMC, the new version of the test will aid medical schools in finding students “who you and I would want as our doctors.  Being good doctors isn’t just about understanding science, it’s about understanding people.”[1]

To which I reply:  Will wonders never cease?  We’re going to help medical schools make humanistic doctors with better people skills by making sure premed students are exposed to humanistic medicine as it filters through introductory psychology and sociology courses.  Had AACP personnel perused a sampling of introductory psychology and sociology syllabi, they might have paused before deciding to cultivate this new skill set through introductory social science courses, which, in this day and age, devote little time to theories of personality, family structure and dynamics, psychosocial development, and psychodynamics – the very topics that engaged me when I studied introductory psychology in the fall of 1969.  Still less do today’s introductory social science courses permit psychosocial and ethical consideration of health-related issues; for the latter, one seeks out upper-class courses in medical sociology, medical anthropology, and, of course, medical ethics.

If it’s a matter of choosing general nonscience courses that frame some of the ethical and cross-cultural (and racial and gender-related) issues tomorrow’s physicians will face, introductory philosophy courses in moral philosophy and/or ethics would be far more to the point.  But I am a historian and my own bias is clear:   At the top of horizon-broadening and humanizing courses would be surveys of nineteenth- and twentieth-century medicine in its cultural, political, and institutional aspects.  I offer two such seminars to upper-class history majors at my university under the titles “Medicine and Society: From Antebellum America to the Present”  and “Women, Their Bodies, Their Health, and Their Doctors: America, 1850 to the Present.”  Both seminars address doctor-patient relationships over the past two centuries, a topic at the heart of the social history of medicine.

But let’s face it.  Requiring premed students to take a few additional courses is a gesture – something more than an empty gesture but still a weak gesture.  There is every reason to believe that students who spend their undergraduate years stuffing their brains with biology, organic chemistry, and physics will  approach the social science component of premed studies in the same task-oriented way.  The nonscience courses will simply be another hurdle to overcome.  Premed students will take introductory psychology and sociology to learn what they need to know to do credibly well on the MCATs.  And, for most of them, that will be that.  Premed education will continue to be an intellectual variant of survivor TV:  making the grade(s), surviving the cut, and moving on to the next round of competition.

The overhaul of the MCAT is premised on the same fallacy that persuades medical educators they can “teach” empathy to medical students through dramatizations, workshops, and the like.  The fallacy is that physicianly caring, especially caring heightened by empathy, is a cognitive skill that can be instilled through one-time events or curricular innovations.  But empathy cannot be taught, not really.  It is an inborn sensibility associated with personality and temperament.   It is not an emotion (like rage, anger, joy) but an emotional aptitude that derives from the commensurability of one’s own feeling states with the feeling states of others.  The aptitude is two-fold:  It signifies (1) that one has lived a sufficiently rich emotional life to have a range of emotions available for identificatory purposes; and (2) that one is sufficiently disinhibited to access one’s own emotions, duly modulated, to feel what the patient or client is feeling in the here and now of the clinical encounter.  Empathy does not occur in a vacuum; it always falls back on the range, intensity, and retrievability of one’s own emotional experiences.  For this reason, Heinz Kohut, who believed empathy was foundational to the psychoanalytic method, characterized it as “vicarious introspection,” the extension of one’s own introspection (and associated feelings) to encompass the introspection (and associated feelings) of another.

Everyone possesses this ability to one small degree or another; extreme situations elicit empathy even in those who otherwise live self-absorbed, relationally parched lives.  This is why psychologists who present medical students with skits or film clips of the elderly in distressing situations find the students score higher on empathy scales administered immediately after viewing such dramatizations.  But the “improvement” is short-lived.[2]  An ongoing (read: characterological) predisposition to engage others in caring and comprehending ways cannot result from what one team of researchers breezily terms “empathy interventions.”[3]

If one seeks to mobilize a preexisting aptitude for empathic care giving, there are much better ways of doing it than adding introductory psychology and sociology courses to the premed curriculum.  Why not give premed students sustained contact with patients and their families in settings conducive to an emotional connection.  Let’s introduce them to messy and distressing “illness narratives” in a way that is more than didactic.  Let’s place them in situations in which these narratives intersect with their own lived experience.  To wit, let’s have all premed students spend the summer following  their junior year as premed volunteers in one of three settings:  pediatric cancer wards; recovery and rehab units in VA hospitals; and public geriatric facilities, especially the Alzheimer’s units of such facilities.

I recommend eight weeks of full-time work before the beginning of senior year. Routine volunteer duties would be supplemented by time set aside for communication – with doctors, nurses, and aids, but especially with patients and their families.  Students would be required to keep journals with daily entries that recorded their experience – especially how it affected (or didn’t affect) them personally and changed (or didn’t change) their vision of medicine and medical practice.  These journals, in turn, would be included with their senior-year applications to medical school.  Alternatively, the journals would be the basis for an essay on doctor-patient relationships informed by their summer field work.

I mean, if medical educators want to jumpstart the humane sensibility of young doctors-to-be, why not go the full nine yards and expose these scientifically minded young people to aspects of the human condition that will stretch them emotionally.  Emotional stretching will not make them empathic; indeed, it may engender the same defenses that medical students, especially in the third year, develop to ward off emotional flooding when they encounter seriously ill patients.[4]  But apart from the emotions spurred or warded off by daily exposure to children with cancer, veterans without limbs, and elderly people with dementias, the experience will have a psychoeducational yield:  It will provide incoming med students  with a broadened range of feeling states that will be available to them in the years ahead.  As such, their summer in the trenches will lay a foundation for clinical people skills far more durable that what they can glean from introductory psychology and sociology texts.

Those premed students of caring temperament will be pulled in an “empathic” direction; they will have an enlarged reservoir of life experiences to draw on when they try to connect with their patients during medical school and beyond.  Those budding scientists who are drawn to medicine in its research or data-centric “managerial” dimension[5] will at least have broadened awareness of the suffering humanity that others must tend to.  Rather than reaching for the grand prize (viz., a generation of empathic caregivers), the AAMC might lower its sights and help medical schools create physicians who, even in technologically driven specialties and subspecialties, evince a little more sensitivity.  In their case, this might simply mean understanding that many patients need doctors who are not like them.  A small victory is better than a Pyrrhic victory.


[1] Elisabeth Rosenthal, “Molding a New Med Student,” Education/Life Supplement, New York Times, April 15, 2012, pp. 20-22.

 [2] Lon J. Van Winkle, Nancy Fjortoft, & Mohammadreza Hojat, “Impact of a Workshop About Aging on the Empathy Scores of Pharmacy and Medical Students,” Amer. J. Pharmaceut. Ed., 76:1-5, 2012.

 [3] Sarah E. Wilson, Julie Prescott, & Gordon Becket, “Empathy Levels in First- and Third-Year Students in Health and Non-Health Disciplines,” Amer. J. Pharmaceut. Ed., 76:1-4, 2012.

 [4] Eric R. Marcus, “Empathy, Humanism, and the Professionalization Process of Medical Education,” Acad. Med., 74:1211-1215, 1999;  Mohammadreza Hojat, et al., “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Acad. Med., 84:1182-1191, 2009.

 [5] Beverly Woodward, “Confidentiality, Consent and Autonomy in the Physician-Patient Relationship,” Health Care Analysis, 9:337-351, 2001.

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

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A Musical Offering

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_________________

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.