The Yale Journal for Humanities in Medicine

The Accurate Eye, The Truthful Ear
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Howard Spiro, M.D.
howard.spiro@yale.edu

MEDICAL EDUCATION

With the end of quotas and other restrictions after World War II, getting into medical school has depended on grades and college accomplishments, the statistics and bar graphs of industry. The trouble with relying on MCATs, GPAs, and all the numerical assays of intelligence comes in what is measured. Intelligence is more complicated than knowledge, as I have just suggested.  Some rethinking is in order about how we choose medical students and what we choose them for.

One thing is sure: medical education drags on entirely too long. Surgeons can be as old as 40 before they start on their professional careers. Surely, students could be tracked much earlier, future clinicians following one curriculum, future surgeons another,  and those planning to do research another. Subspecialists could also benefit from earlier tracking.  Does someone planning to be an ophthalmologist, for example, really need to know the bones and joints? Should a gastroenterologist devotee learn much about the the eye?  Some will argue that good clinician should know everything, but others may concur that they need only to know where to find the answers. Life is short and the art has grown longer than ever. 

In ancient Greece knowledge came from either measuring or not measuring. I trace the conflict between Reason and Intuition back to the antipodes of the physicians labeled Hippocratic and the more priestly group called Aesculapian.  The Hippocratics convinced their students that they were professionals who knew more than their patients, where the Aesculapians relied on persuasion and healing words, fortified by wine, for the supplicants who came to them in the temples.

In the Middle Ages, knowledge was divided into the quadrivium which had to do with measurement or the trivium which was verbal. Measuring was the measure of knowledge. The emphasis on quantification grew even stronger in the 18th century with the Enlightenment, that remarkable collection of intellectuals who adopted mathematics as the  “science of sciences.” With it came birth of modern science and the certainty that the scientific approach can explain everything on this earth, what Isaiah Berlin has labelled the "scientific fallacy.”

That belief is where modern medicine may have gone astray. There is science and there is immediate knowledge, intuition if you will. Science is the process by which new knowledge is created out of facts that are quantifiable and verifiable. Intuition in contrast is what we know immediately -- without conscious thought, knowledge that cannot be measured.  Bertrand Russell warned, “Science does not include art or friendship or various other valuable elements in life.”  Henri Bergson put it, "Science deals with matter, intuition toward life.” Or as Martin Buber urged, in what could be advice for the medical profession, "Not looking at the other but a… stirring one's being into the life of the other." 

Science deals with models and hypotheses that are tested by experimentation.  Humanities, which is intuition writ large, deals with concepts and stories and impressions that are open to many different interpretations.

People do not live by reason alone.  Many of us need love, mystery, passion and excitement.  So it is not surprising that in the 18th and 19th centuries the Counter-Enlightenment came along as a reaction, or an antidote, to pure reason. That response which culminated in Romanticism, somehow  passed right by medicine leaving very little influence on mainstream medicine whose advances continue on hard data alone.  Happily, the firewall between mainstream medicine and its complementary cousin is gradually falling under the onslaughts of postmodern enthusiasm. 

Not only did they bring back to the fore inner life and religious life and mystical experience, but Romantics praised self-discovery and individuality, intuition and revelation, variation, and the gamut of all the wild emotions that the rationalists had rejected in favor of form and uniformity.  Among its many benefits, the Enlightenment brought both liberal democracy and the scientific revolution.  Nevertheless, we humans are made up of body, mind, and spirit; our inner life counts for a lot.  We cannot explain all that happens to us nor all that we feel,. which is why reading the Romantic poets is so attractive to college students and would be especially helpful to those who plan to be physicians.

In western medical practice the rationalism of the Enlightenment has so triumphed that what we physicians cannot measure we do not trust -- or believe. We need more passion in medicine than Osler's old admonition for equanimity permits.  Our emotions give depth to our medical activities.  Computers have far more memory and our machines see far more deeply than we do.  But we can listen to our patients and guide them,  and that unique capacity will make doctors far more comforting even when  machines take over our work of diagnosis and treatment.  That duty to them will prove more important than ever thanks to the miraculous advances of science and technology in the 20th century. The future will require a change in how we prepare  college students to become medical students and the physicians of tomorrow.  Understand, I am not talking about research scientists, or surgeons for that matter  but rather those of us who make possible the care of the sick.

The abiding faith in science for medicine in the 20th century has led to the "two hurdles" of organic chemistry and the three-year hospital-based residency.  To get into medical school, would-be physicians must do very well in organic chemistry, physics, and other scientific disciplines.  They will probably never use that knowledge again, but studying such matters, like the knightly vigil of medieval times, affirms a loyalty oath to science.  The second hurdle is the gradually lengthening hospital-based medical residency; it is essential to the care of the desperately ill, but it bears little relation to what most practitioners will do for their healthier ambulatory patients in later professional life.  Indeed specialists in such care, hospitalists, are forging a new medical discipline. 

Continued
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