The Yale Journal for Humanities in Medicine |
 |
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.
There is a new and welcome diversity among physicians, but advances in technology should make it possible for us to include even more kinds and conditions of medical students. More than half the new physicians are women, many are African-American, more are of Asian descent. A lot more people can now consider a career in medical practice. Nurse-practitioners and physician-associates and assistants are only the vanguard. Very recently a deaf doctor pointed out that becoming a cardiologist is no longer inconceivable for her, now that echocardiography displays have become the dominant mode for many if not most cardiologists. Looking down the roads, robotic surgery should make it possible for a paraplegic, a quadriplegic even, to carry out operations by remote control, in the blinking of an eye.
There might even be a role for aged physicians in hospitals to raise questions about the goals of caretakers in intensive care units. If practitioners should reflect the diversity of their society, it might comfort us elderly to spy a few octogenarians in the crowds around the bed, gray heads still vertical gazing at the world from our same vantage point.
Physicians have lost confidence in themselves. They no longer consider it professional to help patients by their words, by their person, or by their presence. Some practicing physicians are unhappy enough to leave medicine and far more say they are, but stay put. There are well-known reasons for all this: reduced income, loss of autonomy, loss of respect and dignity; too little time to do all that should be done and not enough leisure. That loss of self-respect comes in part from rules and regulations, oversight that hobbles our activities. Worse, physicians feel threatened by malpractice suits and defamed by its ever-present possibility. Until the malpractice threat is ended, I doubt there is much that will reduce the costs of medical care that blends into defensive medicine.
A poignant issue of the Harvard Medical School Alumni Bulletin in 2003 devoted most of its pages to the growing disenchantment with medicine. The usual problems came up. Autonomy headed the list, not so much for patients, for that battle is won, as for the freedom of physicians to make the choices they think best for their patients. Several respondents asserted that autonomy also required the financial security to exercise that freedom. In 2004 graduating medical students choose fields like dermatology or non-interventional radiology to make a good living while still enjoying a leisurely life. "Lifestyle, lifestyle, lifestyle" seems to be the rule. Beyond autonomy, dignity -- which I take to mean a decent level of respect -- still is cherished by many physicians.
It is the “dumbing down" of medicine that is in part responsible for the doctors’ distress. I do not mean the computer access or the diagnostic pathways or the new arrivals in medicine as much as the straitjacket that confines what doctors can do or say. Patients are seen as modular, their diseases more important than they are; the protocols and "best practices" mandated by professional groups guide, and constrain, what the doctor does.
That raises a question of whether medical practice requires only the "best" people and how you define "best"? There are so many levels and kinds of intelligence. How smart does a physician need to be to make diagnoses in the 21st-century? Or do you need just to be a good communicator who can connect with patients? What is the relationship of basic science to medical care and bedside medicine? And in the 21st Century, how should training for medical practice change, in college preparation as well as in medical school?
Do physicians need to be intellectually agile or just "street smart"? The "intellectuals" prefer the Ph.D. route. You need to be compulsive to be a good physician, with a sense of duty, a capacity for loyalty, and -- most of all -- an interest in people, but there is little about post-modern medical practice that needs the grounding in science required for a "rocket scientist."
There are many different ways to think about intelligence and what physicians need to know. You can learn from books and from experience, but to be a doctor you need to apply what you know in daily life. Another kind of intelligence involves emotional maturity. Intelligence can also be categorized as knowledge of facts like vocabulary or mathematics or it can be more fluid, like the ability to reason and abstract. But which are the right ones for physicians? For research? For clinical care? The qualities that make a good scientist are unlikely to be the same as those that make for a good clinician; some people are good therapists where others find their ability at pattern recognition and that makes them excellent radiologists.
Yale medical students tell me how rarely they turn to textbooks, but search the computerized summaries like Up-to-Date for what is necessary and practical in the care of patients, that is, when the answer is not already in the palm-pilot of their hand, so to speak.
Increasingly experts show the clinicians what has gone wrong, the diagnosis on some image. Then a computer program advises the recommended therapy to those practitioners who ask for advice. The crucial step follows: conversation between the clinician and the patient helps to decide what should -- or more important even -- what should not be done from among the growing pile of protocols.
That suggests that clinicians more than ever should be the mediator between the machines and our patients, and that that will surely continue to be an important duty. Happily, science has brought us to where we are and no way do I decry the advances that have made clinical practice far more effective than ever before. But not all physicians need the kind of training that has made that possible, and they do need more human understanding. I did not know how to make a match to light the cigars I once so cherished, but I knew how to smoke them.
Such rapid access to medical knowledge provides a vision of doctors looking up the “best practice" for protocols and guidelines on the PalmPilot to take care of patients. Guidelines quickly turn into rules. “Quality care” will seem to be reached if following protocols is rewarded financially by carrots of gold. Physicians can earn “frequent-flyer” points for “quality care” by ordering all appropriate routines, but it remains uncertain whether such practices will lead to better outcome, or just to a well-intentioned goose step without any proof that it improves outcomes.
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.
Physicians move between two worlds, that of science which provides us with knowledge and the very substantial advances against disease, and which gives us our ideals. We live also in the world of the people who are our patients and who suffer pain, keep hope alive and look for happiness and even joy in their lives. We treat patients in whom personal, social, and psychological components make a difference in how they feel, but we know so much more about lupus than lust that no physician can be blamed for believing that quantitative methods can yield answers even to desire. Yet there is a difference between using the works of science and knowing how to go about discoveries. To turn medicine into a science alone may mistake the means for the end.
Like most other adults, 21st-century physicians grow a carapace of callousness to protect themselves against erosion by too much empathy. The reasons are many, but it may be that reading will enlarge the vision of postmodern physicians to get us to understand our patients as people with stories to tell. That might even mitigate the burnout ever more common among our colleagues.
Reading stories of people and their lives in the world could fan the embers of empathy in physicians and give us more joy in sharing and interpreting and sometimes in helping the lives of others. The good physician should find joy in helping others. Caring can be a kind of cure for apathy and burn-out. This should not be just a means to an end, psychotherapy for the doctor, but should aid us in understanding the wide experiences of people we label patients. Oscar Wilde put it well, “Nature imitates art." We have to be taught to see, we can be taught to listen -- and even to feel once again.
We need to recognize and to cherish feelings and emotion in ourselves. Boredom and burnout, apathy it has been called, now so rampant might be replaced by more noble emotions if we allowed ourselves to feel with our patients. Medicine might even turn away from the business it has become and regain its honor as a calling.
It is no surprise that we doctors distrust empathy: Selected by victories, we competed for medical school by hard-edged achievement and we were taught that hard work brings all the answers. We have too little time for reflection, we are pressured to get everything done. There is little leisure in practice, and contemplation finds no bench around the hospital.
Empathy begins to fade when medical students are selected solely for their scientific knowledge, and know it. The kinds of people I would like to have as my doctors are often swept out by the medical school requirement for organic chemistry. Passing "orgo" may be a surrogate for the energy and industry required for medical school studies, but it eliminates the very people who could be the caring physicians of the 21st-century. Passing a course in John Milton might be as good a surrogate as “orgo.” For those who choose, I would replace organic chemistry with a social science, and I would require more exposure to the humanities for pre-medical students. Ineed, Mt. Sinai Medical School and Tulane in New Orleans are experimenting with just such programs, I have learned.
Empathy is ignored by a rote recital of the "case history" sterilized of any personal note by our medical jargon that attempts to be objective. Physicians so shun individuality that they label a 75 year old professor of English with dysphasia a "male", a 39 year old grandmother of 21 a "female, " and even substitute "pediatric population" for a group of children.
It would be presumptuous for me to add to what has already been written about the importance of narrative in fashioning the character and furthering the education of physicians, and all that they can learn from the lives of their patients. But I want to repeat my praise of rhetoric, the power of persuasion, once so important to doctors when they could do so little else; it needs a rebirth in medical practice. Physicians can be more than conduits of pills or procedures and we should be more than technicians.
I do not propose to pile stories of illness on top of the already overloaded curriculum, but physicians should share the stories they hear, with their colleagues of all varieties Conversation is the key. Continuing discussions on medical rounds and in the doctors’ dining room, about patient-doctor encounters, the epiphanies of medical care as well as of human relationships, will help to shore up the passion of empathy. After all CAT scans and MRI imaging have no human face.
Let me make a distinction among the recent attempts to control medical practice. The HMO controls of the eighties and nineties were based solely on financial reasons, and they were secular with their frankly economic incentives. They are being replaced, however, with strictures apparently more respectably based on "evidence". That second approach ,by physicians and not economists, has taken on a moral intensity that reflects the intolerance of historical religions. It is hard for the irreverent practitioner to argue against “evidence” sanctified in the “literature,” like “inerrancy” in the Bible. We have to be wary of the implied moral superiority of what is labelled “evidence.”
Most of the Harvard respondents I mentioned earlier wanted more time to spend with their patients and to make decisions with and for them. That sounds a lot like what paternalistic doctors used to do. They also worried a lot about malpractice suits and their huge student debts. Requiring recent graduates to spend two years of civic service to retire their debt would improve medical care at the same time as it freed physicians to choose the fields they really wanted. And it goes without saying that the rush to malpractice suits must be countered. Quality of care and safety of patients were also high on the Harvard list.
What is to be done?
One of the more disheartening aspects of current medical practice is how little time remains for contemplation, so little time for leisure even in academic life -- or especially in academic life. At Yale Medical School most events were scripted, meetings took place for information transfer, and social events that encourage collegial friendships had disappeared. It seems unlikely that we can recapture that more leisurely, more contemplative, approach to life and to our patients UNLESS we double the number of medical care-givers now in practice, whether nurse- practitioners or some other kind of physician-extende even if increasing the supply also increases costs.I will know that there are enough doctors when patients complain, “I just couldn't get out of my doctor’s office. She just wanted talk to me about all sorts of personal matters!”
Clinical reputations used to be built on coming to correct or at least helpful conclusions on insufficient data. But now there is a new-found insistence on certainty. During some years at Yale Law School, at the borders of law and medicine, I was struck by how differently law and medicine treated certainty. At Yale Medical School students learn that if they look wide enough and deep enough, they will come up with an answer. By teaching that there is only one truth, we feed the greed for certainty. Yale Law School more genially proclaims the varied meanings of truth. They use the case method there: after a case has been discussed and a framework for judgment found, the instructor may ask, "Well, what if the man had been a woman? How would that change things?" Then the discussion begins all over again. Yale’s medical school teaches certainty with confidence where its law school teaches uncertainty with arrogance.
The trouble is that almost everything has been turned into a disease , which has to be seen or scan. Physicians believe that almost every symptom has an organic basis if you try hard enough to find it and if your instruments are up-to-date. Ignoring metaphorical laments like "I've had it up to here!" Or "I can't take that any more of that!", gastroenterologists are convinced that nausea , for example, always arises from delayed gastric emptying. They do not like to consider that nausea could indicate revulsion at the dilemmas or struggles that patients find themselves in, what used to be called the psychosocial aspects of medicine.
"The eye is for accuracy, but the ear is for truth". It is easier to make diagnoses by CAT scan or MRI if you have an eye for patterns than to listen to the patient, to revive what the Greeks called catharsis . Medical treatments are vastly better now than 60 years ago, but it is too bad that physicians have forgotten how much they can do for the patient by being here, by their words and even by their person
CONCLUSION
I come finally to what we can do for the physicians, without whom nothing. My theme has been that the growing power of computers with their extraordinary linkages and memory makes the duties of physicians easier, but more time-consuming. The human aspects of the care they can give will constitute an essential element in 21st-century medicine.
But physicians need help and protection Doctors will always make mistakes, will always have doubts about their own competence and will always feel unworthy at the early death of a patient. Increasing the number of doctors or physician-extenders will give them time for those human duties, enough time to do a good job, and to have some leisure for recreation and contemplation. Physicians are human, will make mistakes and more than rarely will be frustrated and angry and even bitter.
Physicians are experts licensed by the state and they should be protected against unwarranted malpractice suits. If that is not done soon, physicians will increasingly regard every patient as a potential plaintiff and will continue to order every test in the books—and some not yet there. Along with that, however goes some chastisement for those doctors who do not work carefully and loyally enough for their patients. After all is said and done, to a 19th-century physician the life of the 21st-century physician would look pretty good!
I have talked of science that measures and of intuition that comes unbidden. While science explores the universe of the cell, we physicians will learn more about our patients and ourselves if we include what is not seen in our calculus. Modern medical science has left too many physicians feeling that they are only conduits of other powers, of pills and procedures. Managed-care that treats physicians and patients as modules reinforces that error. Protocols and “evidence-based” pathways that I have doubtless maligned assert it.
Our words are the key to our place and our power. Suggestion plays a powerful role in the placebo- response, expectation and faith strengthen that response. Words can exhort the healthy: just as speeches fire us to war or melt us to tears. Rhetoric it used to be called. Words can mobilize healing in the sick, even if science is needed for cure. That must be why medical journals have opened their pages to poetry and narrative, philosophy and faith.
Physicians must recognize once more that not all pains come from disease. What patients learn to call pain to get our attention comes from anger, fear, tribulation, and the silence of sorrow that has no tears. Words of reassurance can alter the vigilance with which people regard their bodily sensations and their perception of their health. If we are lucky sometimes our explanations can provide "the healing fiction, the meaning that quickens". Understand, I'm not suggesting lying, but optimism and hope can help.
Mainstream physicians should not be afraid to rely on suggestion as therapy, words that can be taken in as readily as our pills. Science and intuition are not mutually exclusive. Physicians need not feel guilty at turning to the magical side of their work for part of our magic lies in caring for the patient. On that interdependence hangs the healing of spirit and mind. Neurobiological pathways may run from brain to toe, but I halt at the belief that the mind can control disease. The modern loss of faith leaves us yearning for visions of Paradise. Healing comes from the Creator however named and framed, but in our workaday world there are no miracles:cures comes only from science and technology. All the talk in the world will not release the schizophrenic as readily as modern chemistry. All the love in the world has not very often cured cancer. The onslaught of cancer is like the force of a fire hose that sweeps all before it. The mind can control normal physiology just as you can shut off a garden hose by squeezing your fist, but the power of pathophysiology which is disease requires methods more potent than hope.
In closing, let me thank you for your patience, but let me leave no doubt that I feel blessed to have been a physician. I would jump at a second chance! I might choose neurobiology, but I would certainly choose patient care, to feel useful. Spiritual arrogance it may be, but it's not a bad feeling at the end of the day -- or at the end of a life.
This article was first presented as the Davies Scholar Lecture at the American College of Physicians annual meeting, New Orleans, May 2004.
Published: August 19, 2004