SEPTEMBER 11, 2016
IN THE SUMMER of 1968, my friend Lisa and I spent hours on the floor of her family’s screened porch playing a board game called Careers. Like Life, another game popular in that era, Careers aimed to instill in young baby boomers stolid postwar American values. The goal was to select an occupation (doctor, lawyer, engineer, etc.) and accumulate “victory points” for fame, money, and happiness. Each career offered distinct advantages — the engineer got extra victory points for landing on a particular square, and so forth — except, as I recall, “the doctor.” The only advantage of being the doctor was that you got to pretend you were a doctor.
I always chose to be the doctor.
For reasons likely, and embarrassingly, having to do with my father being a surgeon, and my being a bright and ambitious girl lucky enough to come of age at the dawn of the women’s movement, I was in love with the idea of becoming a physician. As Lisa and I moved our pieces around the board, I imagined my future doctor-self: wise, brave, heroic.
Surprisingly, my romantic notion survived the slog of medical school, the 36-hour shifts of internship, and the less-than-glamorous realities of practicing primary care. For two decades, hospital politics, insurance headaches, and even the occasional threat of a malpractice suit failed to dampen my dewy-eyed enthusiasm.
Then, about five years ago, I found myself slipping into malaise. At first I thought I was simply getting old, no longer quite up to the responsibility of caring for so many sick people. But it wasn’t so much weariness as nostalgia — nostalgia for handwritten notes elegantly penned on paper charts, for long discussions with colleagues about interesting diagnoses, for moments during patient visits to admire vacation photos and hear about grandkids … Most of all, I was nostalgic for time.
I’ve wondered if I’ve simply drifted into the fogey-ism that has always plagued older doctors, reminiscing about the glory days, “when medical giants walked the earth.” Except that younger doctors have started complaining, too. A resident in his 20s informed me sadly the other day that though he and his fellow trainees haven’t been in medicine very long, “We already feel like we’re losing something.”
Something is ailing America’s doctors. On average, we’re growing more dissatisfied with our work, retiring earlier or choosing part-time schedules, and discouraging our kids from entering the profession; we’re also divorcing, becoming addicted to drugs and alcohol, and committing suicide at well above average rates. What’s more, our discontent is hurting our patients. Studies show that unhappy doctors provide inferior medical care, or opt out of the practice of medicine altogether, which contributes to an increasing shortage of physicians. In a recent interview, Dr. Vivek Murthy, the US Surgeon General, highlighted two current public health crises: the opioid epidemic — and physician burnout.
The misfortunes of professionals who enjoy prestige, generous salaries, and job security may not inspire much sympathy. Still, articles like “How Being a Doctor Became the Most Miserable Profession,” published in 2014 on The Daily Beast, list physicians’ gripes: more patients crammed into shorter visits; high medical school debt and low insurance reimbursements; increasing amounts of tedious data entry and decreasing deference from internet-savvy patients.
This list, though, doesn’t really account for our professional funk. After all, aren’t we conditioned, from early in our training, to work hard and to perform our duties under less than ideal circumstances? To be sure, it may simply be that, over the last decade or so, the gradual accrual of small and large blows has taken its toll. (Some doctors have dubbed the data entry issue “death by a thousand clicks.”) Still, when I consider — or, on a bad day, recite — this litany of complaints, I have the same uneasy feeling as when examining a patient with a long list of symptoms. Something is clearly wrong — but what exactly?
Narratives by physicians, from Hippocrates to Oliver Sacks, have tended to focus on memorable patients, particularly on unusual or ethically ambiguous cases. Recently, however, doctors have turned their diagnostic skills on themselves. Several of these narratives were discussed in Meghan O’Rourke’s 2014 Atlantic essay “Doctors Tell All — And It’s Bad,” which draws on Sandeep Jauhar’s account of his participation in questionable practices for profit (Doctored: The Disillusionment of an American Physician ), Terrence Holt’s exposé of how overwork can lead young doctors to disrespect and even mistreat patients (Internal Medicine: A Doctor’s Stories ), and Atul Gawande’s insider view of expensive and often futile end-of-life care (Being Mortal: Medicine and What Matters in the End ).
A welcome addition to this self-critical canon is Abraham M. Nussbaum’s intelligent and beautifully written new book, The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine. Like a master clinician taking a thorough medical history, Nussbaum, a psychiatrist in Denver and an assistant professor at the University of Colorado School of Medicine, probes the early years of his own training as well as the origins of American medicine in an attempt to sort out what’s gone wrong.
That said, Nussbaum is hardly alone in examining the subject through a historical lens. In just the last two years, Nortin M. Hadler’s By the Bedside of the Patient: Lessons for the Twenty-First-Century Physician (2016), Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (2014), and Barron H. Lerner’s The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics (2015) have all looked to medicine’s past as a guide to its future. Part of what makes Nussbaum’s effort so notable is how young he is. Just 12 years out of medical school, Nussbaum has already concluded that he must retrace his steps to get back on the right track, and that medicine must do the same. His memoir’s intentionally fusty title — “the finest traditions of my calling” is a phrase from the Hippocratic Oath — bespeaks Nussbaum’s affection for the antique.
Fortunately, this affection does not devolve into blind reverence. Nussbaum opens his book with a clear-eyed portrayal of Sir William Osler, the revered father of American medicine. At the end of the 19th century, Osler founded the first modern medical school, Johns Hopkins, on a then-radical principle: doctors should be both scientists and humanists. Osler encouraged medical students to read great literature, and insisted that they learn medicine at the patient’s bedside, a practice then disdained in the established medical schools of Europe. He also required students to frequent the library, the laboratory, and, particularly, the autopsy room, in order to study the anatomical correlates of their clinical observations. This duality — what’s still called “the art and the science of medicine” — now seems fundamental to the profession. Indeed, it is this conceptual contribution that has earned Osler’s name a place on countless medical societies’ letterheads and hospital conference room plaques.
Yet Osler himself, Nussbaum contends, did not always embody the ideal of the scientist-humanist. (I could practically hear Sir William’s disciples gasping as I read this passage.) In fact, Osler publicly praised a surgeon who turned a 19-year-old man, Alexis St. Martin, into a walking physiology experiment, and touted him as a model physician. St. Martin had a fistula connecting his stomach to his abdominal wall and the surgeon alternately fed and starved the youth to observe the workings of his exposed digestive tract. When St. Martin died, Osler hounded the grieving family to permit an autopsy. They refused, and fearing Osler’s dogged persistence, positioned armed neighbors around the grave. Nussbaum observes, wryly: “If Osler is the ideal physician, then the ideal patient may be a corpse.”
In a “white coat ceremony,” a rite of passage for first-year students at most medical schools, Nussbaum and his classmates received short white medical jackets (science) and a book of poetry and prose (art). Even at that early stage in his career, Nussbaum was uncertain about how comfortably those two pillars of his profession coexisted. That skepticism only grew as his training progressed:
Our formal education was often truly humanistic. Our medical school employed a department of scholars in social medicine who introduced students to the economics, ethics, and history of medicine and scores of learned clinicians who impressed upon us the need to be humane in our care of the ill. […] Yet on my clinical rotations I learned something different — how to see people as compendiums of parts and money. When residents and attendings quizzed me about a patient, they never asked about his or her strengths or passions; they wanted to know about the physical exam findings, lab values, and pathophysiology. When no one asks about something, you learn that it is not important.
The central point of Nussbaum’s book is that the tension in medicine between art and science — evident in Osler’s time and still strongly present in the 1990s, when Nussbaum became a physician — is at the heart of why patients today so often feel poorly cared for, and why doctors so often feel unfulfilled. An imbalance between science and humanism, and particularly an overreliance on classification and quantitation, has distracted physicians from the primary goal of our work: the relief of suffering. Nussbaum references Foucault’s 1963 classic The Birth of the Clinic: An Archaeology of Medical Perception:
Foucault described the moment when physicians combined dissection with clinical practice as the “great break in the history of Western medicine.” Instead of seeing themselves as people designated by society to attend to people who are suffering, they began to think of themselves as scientists. We now understand ourselves as people who observe and measure the body, hypothesize about its function and dysfunction, and then prove and disprove the resulting theories. When physicians began understanding themselves as scientists they developed antibiotics, anesthesia, and asepsis. With these disruptive and innovative technologies, they transformed what it means to care for the ill. They also transformed themselves.
And not entirely for the better, Nussbaum believes. Doctors’ fixation on “observing and measuring” has derailed medicine, and hurt doctors, too. Some doctors make patients feel like specimens, like “money and parts,” as Nussbaum realized when he was a trainee. Plus, increased requirements for digital documentation — some mandated by the Affordable Care Act — force a doctor to type during a visit or, worse, gaze at a computer screen instead of the patient’s face, dehumanizing the patient, but also alienating the physician from her job.
Nussbaum also identifies other, less obvious ways in which “observing and measuring” have negatively affected medicine. One is the focus, in recent years, on evidence-based medicine. It would seem an unalloyed benefit to the patient, not to mention satisfying to the doctor, to prescribe only those treatments proven effective in large clinical trials. Yet these trials, Nussbaum argues, can’t take into account each individual’s unique story. He gives the example of an intermittently suicidal Vietnamese immigrant named Bao, who first became sexually active at the age of 43. Her internist prescribed birth control pills, an intervention well supported by data about the safety and effectiveness of oral contraception. But Nussbaum, serving as Bao’s psychiatrist, subsequently learned that Bao’s new sexual partner was, in fact, a police officer who’d been on highway patrol and stopped to help her when her car broke down, and then told her he “liked Asian ladies.” Nussbaum writes:
A patient presents with a problem, and a physician offers a medical interpretation of the problem. The physician-as-technician then efficiently and effectively selects an evidence-based intervention for the problem [… But] [e]vidence-based medicine guides […] will never be able to rate how suitable a particular sexual partner might be or whether a patient will become suicidal after having sex with a police officer.
Standardization and quality improvement are likewise well-intended efforts in modern medicine, but, according to Nussbaum, they have similar limitations. He takes on the widely admired Atul Gawande, who had suggested — in his 2012 New Yorker article “Big Med” — that doctors should aim to provide patients with the kind of uniformly good service and quality offered to patrons of the Cheesecake Factory. The argument seems sound at first blush:
Hospitals, like the Cheesecake Factory, could be improved if administrators studied best practices, standardized those practices, and then implemented them. […] It often takes physicians decades to introduce innovative practices into medicine; the Cheesecake Factory line chefs can master new recipes in days. Medicine, claimed Gawande, must be similarly standardized.
The medicine-cheesecake analogy falls apart, however, when we remember that human connection is fundamental to healing. “Service” and “quality” are not enough:
When we compare medicine to a standardized meal, we should ask what is lost in the process. […] Eating a beet salad prepared by a chef for restaurant patrons is a different experience from eating the same dish prepared for a potluck supper, a romantic meal shared by lovers, or an institutional meal served to prisoners, let alone a ritual meal like a familial Seder, a communal Iftar, or a prasada offering. […] When we focus on technique and outcomes, without concern for who prepares the meal for whom, the experience of the meals is neglected. Food becomes fuel.
When we extend this approach to the hospital and the clinic, the body is reduced to a collection of parts.
Nussbaum is not anti-science; he just wants to restore a balance between science and humanism: “[M]y belief is that the best hope for medicine lies in physicians seeing patients as particular, unique individuals.” He finds models for this ideal physician in unexpected forms, including Neil, his twentysomething, muscle-bound CrossFit coach. Nussbaum devotes a delightfully geeky chapter to his experiences as a client at the popular gym franchise, in which he admits: “I sometimes fantasize about leading patients through chest-to-bar pull-ups and double-unders and Turkish get-ups.”
I’ve had this fantasy myself. Most patients I see have conditions stemming from poor diet, inactivity, and social isolation. They need a life coach as much as they need a doctor. Like Nussbaum, I’m tempted to push the boundaries of my role — to drag patients out of the exam room and out for a walk in the sunshine. Sometimes I’m even tempted to offer non-medical advice: go ahead and have that third baby, quit that job, dump that jerk.
Nussbaum finds his most important mentors in other doctor-writers. He recalls how My Own Country (1994), Abraham Verghese’s memoir about his work as a physician during the AIDS epidemic, moved him as a medical student and again when he read it years later. Verghese, Nussbaum explains, carries on the best of the Oslerian tradition:
Verghese developed an Osler-style proposal for renewing medicine through reading literature and carefully performing physical examinations [… And he] faulted healthcare’s financial hierarchy for discouraging humane encounters with patients.
Nussbaum also finds inspiration in God’s Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine, Victoria Sweet’s 2012 memoir about practicing medicine at the United States’s last almshouse, Laguna Honda, in San Francisco. Sweet, a physician and medical historian with a particular interest in the medieval nun and healer Hildegard of Bingen, treated her indigent patients, many of whom stayed at Laguna Honda for months or even years, with premodern remedies: herbs and potions and, most importantly, time and attention. She sees the physician not so much as someone who does things to people, but as someone who tends to them, as a gardener tends to plants. Nussbaum ponders Hildegard, somewhat wistfully:
In a cloistered community, the therapeutic alliance between physician and patient was established well before a medical relationship was initiated. They shared a common life and lived by a common rule; their common rhythm was a sung hymn.
Do we need to restore such communities or therapeutic alliances to reclaim hospitals as gardens instead of factories and make physicians gardeners instead of technicians? That would be a dramatic reconfiguration, but perhaps we can still work to reenchant medicine with some of the mystery that has been lost in the modern world.
I don’t think for a minute that Nussbaum is proposing that we adopt medieval herbalist practices and do away with evidence-based medicine. I am struck, though, by his use of the word “reenchant” — his desire to restore to medicine that which is unquantifiable, ineffable, even magical. He seems to be thinking of Hildegard, and of Sweet, in this poignant passage at the end of The Finest Traditions of My Calling:
When I feel especially discouraged by medicine, I make a list of what a reimagined medicine would look like, a medicine where physicians and other practitioners could get to know people intimately, bear witness to the social injustices they suffer, and accompany them to health and justice. On a locked psychiatric unit, my list includes the end of coercive treatment, a shared table where staff and patients could eat together, meetings between inpatient and outpatient teams, and ways to reintegrate patients into the lives of families and local communities.
Nussbaum’s list is not so much a policy proposal as a cry of longing, a yearning for lost love.
Is that really the problem? That we doctors have lost the romance — the enchantment — of medicine? In his acknowledgments, Nussbaum writes, “I distrust romances, but I could have told the story of the past fifteen years as a love story.” He’s referring to his relationship with his wife, but Nussbaum might as well be describing his medical career.
I’ve noticed that when many of my own medical colleagues complain, they sound less like disgruntled employees than disappointed lovers. Well-intentioned correctives meant to address physician burnout — such as teaming doctors with nurse practitioners and other professionals to lighten their workload, supplying scribes to help with administrative work, offering wellness programs and hospital reading and writing groups — can’t restore what’s been lost: the time to engage each patient fully and intimately and establish the kinds of relationships essential to healing.
At a recent dinner honoring graduating senior residents at the hospital where I work, I was asked to say a few words about a young physician I’d supervised. I said that I was impressed by his commitment to his patients, and to one patient in particular, a woman with serious and intractable medical and psychiatric issues. “What makes him such a good doctor to this patient,” I said, “is that he loves her.” And then, surprising my colleagues and, indeed, myself, I asked, “And what is this job about, really, if not love?”