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.
Medicine, Health, and History 