A number of months ago, a second-year medical student e-mailed me to ask about the value of humanities courses in our preclinical curriculum. A humanities major in college, he questioned the overwhelming dominance of medical sciences in his first 2 years of classes.
Science is, and must be, the mind of medicine: It is what differentiates us from quacks, and what patients depend on for their future well-being. Yet some say we should, in addition, teach humanities in medical schools because the applicants preferentially selected for admission are science-techno-geeks.
But that's not true! Among our medical students are musicians, poets, historians, dancers, and artists. They come from many and diverse backgrounds in culture, religion, and language. These humanities aren't extinguished in medical school, although some may be temporarily sidelined.
Still, shouldn't we have required classes in the humanities to emphasize to our students that study of the humanities makes people better doctors?
Sadly, there's not much evidence that it does. In the first half of the 20th century, Germany was a highly educated nation in literature, philosophy, and music. And what this allowed Nazi doctors to do in the death camps was to march their victims to the ovens with prisoner orchestras playing Handel and Bach to quiet them on their way to a cruel death.
Nevertheless, I propose that, although science is the mind of medicine, the humanities are indeed its heart, but for student education in this it is really the patients and their families who are the best teachers they'll ever have: They will witness and be part of great events in human lives by being with and touching, listening and talking to their patients. Each one has a history and is a part of history. Their stories — of courage, love, joy, fear, loss, death — echo the themes that great writers of the past used in their best books, plays, and poems, composers in their operas and ballets, and artists in their finest creations.
Medicine is, I think, the greatest of all humanities. In 1900, life expectancy at birth of an American man was 48 years, and of a woman 51 years. By 2012, it was 76 years for men and 81 years for women, largely due to medical science: public health; vaccines; antibiotics; the causes, detection, and therapies of malignancy, cardiac and lung diseases — and more, much more. What greater humanity could there be than one that has given human beings nearly 30 more years of life?
Dr Jock Murray, from Nova Scotia, said, “Medicine is a human endeavor that uses science as a tool.”
Francis Bacon (called the Father of the Scientific Method) designed that tool more than 400 years ago, replacing centuries of medicine's reliance on the authorities, Aristotle and Galen in the Western world. Bacon's method was based on inductive reasoning in which one asks a question (“I wonder why…?), forms a theory — a hypothesis — to answer it (“Could it be…?”), and then seeks evidence to support or refute that hypothesis. This requires observable phenomena which can be isolated, described, measured, and counted, and then tested with variables and controls. Details of the experiment and results must be written up and made public so other scientists can review and/or repeat the study, and perhaps make changes in — or even overthrow — the hypothesis. In the scientific method, there is never a final “absolute truth,” only the current theory.
I was interviewing an applicant to our medical school who was very twitchy. He could hardly sit still. He made me nervous. I asked him why he was so excited. “Evidence-based medicine,” he said, “at last!” What did he think medical scientists and clinicians did during the centuries before “evidence-based medicine” appeared 22 years ago: divination from the entrails of sacrificial sheep?
What is new about evidence-based medicine is that it is so analytically exacting in the rigor of its comprehensive critique of multiple clinical studies, that it is now increasingly used to design “critical pathways” and “practice guidelines.” These can be of significant value, but no one should think they represent “the truth.” That would be like resurrecting Aristotle and Galen.
There's a problem in routinely applying pathways to any single person, because no unique patient is a cohort, nor is that person a diagnostic label (eg, “the diabetic”). Patients often have non-isolatable phenomena at play, unknown and uncontrolled variables. And much suffering cannot really be objectively observed.
A third-year student presenting a woman to me at the bedside said: “She's had subjective pain.” Well, what other kind of pain is there?
For a doctor to apply even the best of evidence-based data to an individual without knowing that person is risky. One must know his or her often complex medical status, but must also seek to know, so far as time, urgency of intervention, and the patient allows, as much as one can about them — their social situation, education, beliefs, hopes, doubts, supports, and burdens. To initiate testing or therapies without assessing these things is akin to plating bacteria on an unknown culture medium. It's bad science as well as bad humanity.
We now live and work in an age of “informatics.” Eighty years ago, the poet T.S. Eliot asked “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?”
Scientific findings are information; knowledge is awareness of what can be done using that information; and wisdom is deciding whether or not to do it.
Clinicians, inundated with information in the form of over-stuffed electronic medical records, lab and imaging results, medical websites, decision trees, algorithms, screening guidelines, and best practice pathways have a responsibility to carefully evaluate that information and ask whether it is good, and what can be done with it, and — most importantly — whether it is applicable to our singular patient now.
The scholars and doctors who publish evidence-based guidelines repeatedly emphasize the necessity of crafting them to the unique patient, yet other “assessment-of-care” agencies, both inside and outside of medicine, may not be so wise. Several months ago I received a letter from a health insurance company saying that, according to their review of screening guidelines, I appeared derelict in not having obtained annual mammograms for one of my patients. And I did not, I admit, even once recommend mammography to her in any of the 7 years after her double mastectomy for unilateral breast cancer.
Reversals and modifications of guidelines are commonplace: estrogens for all post-menopausal women (yes! — no!), PSA screening for all men beginning at certain age (yes! — no! — well, maybe), CT scans in the ER for children with head injuries (yes! — not always!), mammographic breast cancer screening initiation and frequency (not sure — arguing now), and many others, including a remarkable percentage of practice protocols endorsing certain medications, tests, and procedures that turned out, in retrospect, to make no difference or did more harm than good.
A teacher, when I was a second-year med student, gave me advice for which I will always be in his debt. What he said to me was simple, “Never be among the first or among the last to use a new ‘discovery.’”
That good teacher was a deeply empathetic physician. His son, also a physician, was and is a major force in palliative and hospice care. This family history of compassionate father and son raises a question: Are certain people destined by their genome to be more humane than others?
Functional neuroimaging of the brain (PET scans and fMRIs) suggests that people make important decisions based not just on data (stored largely in the neocortex), but also on how we feel about those data — value judgments — rising from evolutionarily older (and perhaps inherited functioning) areas — the midbrain and frontotemporal lobes.
If it is by feelings that we judge what to do with information, doctors and student doctors need extensive personal contact with patients in vivo not mainly in silico (a term for computer work my residents taught me), because how patients feel about their symptoms, choices, and their doctors, and how doctors feel about a patient's symptoms, choices and them as a patient, significantly affects how each uses medical information.
Whatever students ultimately choose to do or be in medicine, they must spend as much time as they can as medical students, during postgraduate training, and in their practice with their patients. However, this is increasingly difficult. I say difficult because doctors are being more and more separated from patients by business-based computer systems designed for rapid-throughput and billing rather than for thoughtful, hands-on patient care. Physicians are under increasing pressure to “get the work done” in less time to do it than we had before, and the value of our work is judged by how extensively, rather than by how pertinently, it is recorded and recompensed. Many, perhaps most, students and residents spend more time on computers than they do with patients.
We cannot allow the progressive erosion of direct doctor-patient interaction to diminish the role of doctors as, in and of themselves, diagnostic and therapeutic instruments, integrating good science with good understanding of the patient. As the precious time we spend together with them gets less and less, patients may come to be seen as little more than problems to be efficiently solved by following instructions in manuals for maintenance and repairs. And if this happens, medicine will no longer have a proud place among the humanities.
Our work must be defined by our physician's oath, which is not to serve “the system,” but to serve the suffering.
If we can reclaim and exemplify medicine that is true to that oath, our students will receive the greatest rewards that doctors and patients can give to one another: new discoveries and wonderful stories to tell, with rich memories to savor, of the enduring bond formed by our shared humanity.
DISCUSSION
Billings, Baton Rouge: I will say that this is a magnificent preaching to the choir.
Fitzgerald, Sacramento: What I would like the choir to do is rise up in revolution against those current forces which are forcing us to do other than what we wish.
Wolf, Boston: I want to share with you something taught to me by David Littman, one of my early teachers about new medicines… and he said, “It is important to use a medicine as soon as it is released before it develops side effects.”
Hook, Birmingham: I really loved your talk. It caused me to wonder and reflect on the focus of medicine on disease versus health, and the role of the physician as we do that. At least in my opinion, one of the few good things that has happened recently has been the beginning of promotion of preventative health for our patients as opposed to disease. But I don't feel like that is being widely accepted or promoted in our educational efforts at the bedside and in the clinics, I wonder about your thought about that?
Fitzgerald, Sacramento: Only that the promotion of health is really affected by this emotional or value judgment. We are surrounded by agencies who, because they feel righteously strongly about something, begin — and I believe this is very bad for us to do — to blame patients for their own diseases. Most of us of my age and beyond have begun to assiduously read the obituaries to see who is still around. I have noticed these past 15–20 years that obituaries have changed a little. In addition to the description of the good and ill that the dead have done, there is now usually the term “valiant battle against…” So people are fighting. A 95-year-old woman died after a valiant battle against Alzheimer's. I would guess there was nobody battling against Alzheimer's, because she probably didn't know what was going on. But the most impressive was a page and a half really on a quite accomplished man to be admired, at the end of which he died of lymphoma. There was a single sentence added… “and he never smoked.” People tend to get a little overboard, and many of my patients are constantly apologizing to me for not having followed the latest recommendations by these agencies. So we have to be a little careful before we tell men and women how they should live so that they can get old and die old. I'm not sure many people want that. What they want is to get older and die young.
Bryan, Columbia: Faith, I hope you have plans to put together some of the wonderful things you have written through the years. I loved your piece about criticizing the English of your medical student and resident presenters. What bothers me is when people say repetitively, the patient, the patient, the patient… who else but the patient, correct?
Fitzgerald, Sacramento: Well the patient also states, alleges, and denies… it's all very suspect.
Bryan, Columbia: I tried successfully for 30 years to try to teach residents and students to make their first paragraph emphasize that this is the most interesting human being in the greater metropolitan area that everybody should want to take care of. You did this beautifully in a patient you saw on the wards in San Francisco, would you care to elaborate?
Fitzgerald, Sacramento: No, I think we are running out of time. You and I can talk later because I want to recruit you into my army of protest, I really do. You have such influence and such wisdom. We should fight in a sense, not with the age of informatics, but to enrich the age of informatics with that knowledge and with that wisdom.
Zeidel, Boston: I agree, you should compile and publish your writings. The issue that we have with electronic record, which I think we do as group need to fight against, is the destruction of narrative. The way the electronic record is constructed is all about the little bits and pieces in our trainees. We can talk endlessly about how they should write literate histories and take good histories, but when it gets reduced to these little boxes and quantifiable things that there is a problem. The crazy part about it is that Google has invented Boolean searches. We don't even need these data elements because we can search in a decent record for them and pull up populations. I think those of us who have the opportunity that help mold the decision making of our institutions should basically say, you can't just write a decent history then we will not accept the record.
Fitzgerald, Sacramento: It is interesting. I got surveyed by a couple of nurses whose job it is to do this. They're no longer doing nursing, and they review all of the physician notes and tell you whether you're hitting the target areas that the institution wants you to hit, and I flunked. I did. So they offered me a class in smart phrases and templates. I said, “can we talk about this. Let's talk about this, come on over or I will come to you.” And they never spoke again. And I just keep doing what I do. It's easy to do this by not passive resistance but active resistance. Talk to the house staff and the students and say, why don't you write it up as the great story that it is? And they'll do it, but of course then they get walloped by the EMR thing. There are some people who have totally substituted it for the patient. That's quite clear. The only advantage to my mind of the EMR — in addition to the sort of quickness with which we can get things done that used to take a long time — is that it is decreasing malpractice suits because it costs more to have paralegals to go through all that stuff and figure out what's going on. Those who take suits on contingency can't pay out that much money.
Schiffman, Providence: The piece that Charles Bryan was referring to is online. You can Google it. It's called “Curiosity.” Read it. You will be richly rewarded.
Footnotes
Potential Conflicts of Interest: None disclosed.