The Yale Journal for Humanities in Medicine
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The Accurate Eye, The Truthful Ear
Howard Spiro, M.D.
howard.spiro@yale.edu
Modern physicians have concentrated so successfully on the body and its machinery, from muscles to molecules and membranes , that anatomy seems indeed to be destiny. The mind has been dissolved in the brain, and the spirit is nowhere to be found -- if anybody still bothers to look. Everything must be imaged or counted. PET scans may show where depression is lodged, but so far no one has yet scanned the site of sorrow.
This is emblematic of the major shift in medicine that has taken place over the past few decades, from the ear to the eye. I like to quote the old aphorism, "The eye is for accuracy, but the ear is for truth." The eye grasps matters at a glance, but to hear you have to concentrate, you have to listen -- and in the 21st-century doctors prefer the speed with which the images flow from the machines to the slower words of the patient. Yet despite the amazing triumphant advances in medicine, patients are dissatisfied. They want more human interaction, someone to talk to, someone to listen. But medical practice has turned silent once again.
Cynics may ask whether physicians need to be familiar with the humanities to cure pneumonia or prescribe a statin. Of course not! “What is the ‘added value’ of Shakespeare?” they may jibe. But to care for many patients, from AIDS to age, familiarity with “the still sad music of humanity” makes that job far more rewarding emotionally. Reading and talking enrich our perspective.
Confronted with the vastness of the night sky (best seen these days in a planetarium!) and the infinitude of the stars, one can lose oneself mystically in the universe to write poetry or praise, or more hard headedly, one can try to analyze the patterns, to measure what is going on. I want for now to emphasize a clear distinction between these two approaches of physics and poetry which stand for Science and Intuition. The knowledge of science is quantifiable, the certainties of intuition are unmeasurable, however firmly they may be felt. Poetry offers a key to what we physicians miss out on, when we ignore what the humanities can teach us: the mysteries we remember as children, those visions of the ineffable and the sublime that have faded away.
That's why a background in history and humanities can help physicians in their work. History teaches how the past is always returning in the cycle of human passions -- and not always as improvement. Familiarity with the humanities can enrich the physician’s idea of what it is to be human, to rejoice or to suffer, and –- more than rarely -- to yearn for the certainty of religious faith. But pre-medical students may well complain that such accomplishments don't often get you into medical school.
Our forerunners, doctors who could do far less than we, knew that 80% of complaints can be relieved by the right hand of fellowship alone, by being there for the patients. That may have been wishful thinking, but reaching out to patients still is therapeutic and, I will suggest, may rescue us doctors as well from the spiritual crisis, the anomie, that afflicts our profession so overtaken by machines. As we yield our authority to make diagnoses and to select treatments, as our autonomy is parcelled out by computer programs, patients still want our help as individuals. They do not want to be treated as modules, nor do physicians.
On a personal note, this fourth year of the new millennium is significant for me. I began medical school in January 1944. Now it is 2004 and -- spared or lucky-- I am 60 years involved in medicine. I have been fortunate -- some might say blessed -- for I never wanted to be anything but a gastroenterologist -- although today starting afresh, I might prefer neurobiology. In 1944, we gave dyspeptic patients milk and mush; relying on what they told us rather than on what we could see. The ear was still equal to the eye. Our scopes reached only to the pylorus, but not through it, leaving the duodenum unseen. In 2004 powerful agents vanquish acid completely, leaving the dyspeptic gourmet’s appetite unfettered; our aided vision explores beyond the duodenum to scan the entire small intestine. H. pylori, unimagined gastric bacteria back then, have replaced stress as the enemy of good digestion. Where once our patients took dyspepsia as a warning to change their ways and felt guilty when they did not, now they are shrived by antibiotics. They feel better and are without guilt, but they understand a lot less about themselves.
I have been a teacher in a medical school almost all of my working life, which may explain if not excuse the minatory manner of these remarks. A child of the early 20th century, I am bounded by a European-American perspective acquired in a 1930s Boston suburb and almost exclusively "Western" Judeo-Christian in content. My history provides my apology.
In the 1940s, physicians worked by themselves, group practices were very rare in New England, and any group that had physicians on salary was practicing "socialized medicine". Physicians were free spirits, entrepreneurs if you will. The novel The Last Angry Man gives a picture of the outspoken “GP” I had hoped to become.
One doctor-one patient was the rule. Now, all is teamwork, physicians practicing together in swarms of 10 or more, hospital physician teams sharing authority and diffusing responsibility. In our hospitals, a holistic approach is nowhere as helpful as an understanding of pathophysiology and the skills to remedy what has gone wrong. But it sometimes is hard for the family of patients in the hospital to tell who is the physician in charge, sometimes very hard indeed.
More competent than 60 years ago, the average physician today relies far less on the physical examination than formerly. That is as it should be, given the images that show so much. I do not understand the persistent enthusiasm for the "complete" physical examination at a time when clinicians waving an ultrasound probe can find far more than they can feel or hear. Cardiologists provide the proper model relying as they do on echocardiography to show them what they will hear from the stethoscope, still draped symbolically around the doctor’s neck but covered with metaphorical dust.