The Finest Traditions of My Calling
Author: Abraham Nussbaum
The crucial subject of this book is the discontent with healthcare that is pervasive among patients and widespread in physicians. The book examined the deep-rooted, and frequently surprising, causes of a problem that has left swathes of healthcare-seekers ‘disappointed by clinics and hospitals’, and spawned a generation of healthcare practitioners plagued by ‘high levels of fatigue and frustration‘. With heart-felt passion, the author, a psychiatrist, traced the roots of the disenchantment with medicine to its modern-day founding fathers and their heirs, pointing a reproachful finger at the misguided principles of medical training and practice they helped to entrench. Guided by a deep empathy that he admitted makes him identify more with patients than with physicians, the author identified many contributory medical traditions, from cadaver dissections to autopsies, which he argued are focused mainly on ‘exploring pathology for their own sakes than in helping people learn to live with their individual realities’. Drawing wisdom from sages such as philosopher Ivan Ilyich, historian of medicine Michel Foucault, and bioethicist Stanley Hauerwas, the book advanced ‘a renewed vision of medicine’ which is contingent on physicians adopting ‘better ways of seeing patients and of being seen by patients’ (pages xii, 5, 41, 69, 71, 123-128 and 200-201).
Perhaps the most fundamental problem the author identified as the cause for the anguish in healthcare is the transformation of the physician from carer to scientist. The book argued that when physicians acquired the innovations and disruptive technologies that enabled them to see inside the body, they redefined what it meant to care for the ill. The author described how the transformation led to the standardisation of clinical diagnosis and treatment, processes which increasingly became reliant on rigid checklists and protocols, and which emphasised the volume rather than the quality of experiences. Admitting that there is some merit in following an ‘evidence-based script‘, the author nevertheless insists that this undermines what being a physician is about, and it has engendered a dehumanised model of medical care whereby physicians perceive patients as machines with fixable ‘faltering parts‘. He added that this perspective of medicine discourages the physician from seeing the patient ‘as a particular person shaped by his or her particular communities and experiences‘, but rather as someone who is ‘a representative of a population group’ (page 36 and 256).
The book provided a very insightful appraisal of how the modern concept of medical care, and its insensitive perception of patients, emerged. Maintaining that the indifferent attitude of physicians to patients is not in-bred, the author traced it to the practices they inculcated during medical training. Noting that such practices are prevalent as ‘the subtext of every class and lab’, the author argued that they encourage physicians to see the body ‘as a machine‘, and not ‘as a mystery or a wonder or an embarrassment‘. The author illustrated this with the prominent example of dissecting cadavers, a medical convention which he asserts leaves physicians ‘unmoved‘ – seeing only body parts, they become unable to identify with the deceased as a person. Arguing further, he said cadaver dissection converts the body ‘into a book we could read’, but adds little in terms of knowledge, the process seemingly entirely geared toward ‘our transformation from student to physician’. The book also discussed other practices which constitute the ‘hidden curriculum‘ of medicine, and which implicitly promote the detachment of physicians from patients; these included clinical rotations in which trainers were only interested in the ‘pathophysiology‘, and not in the ‘strengths and passions‘, of patients (pages 29-34 and 49).
One of the prominent villains in this book, who the author asserted greatly contributed to creating the inimical perception of patients by physicians, is no less than William Osler. The book contended that Osler, widely acknowledged as the leading pioneer of modern medicine, conceived of his own patients more as sources of scientific knowledge and less as human beings. The author pointed out that Osler, by developing a relationship with his patients that ‘could more accurately be described as that between scientist and subject‘, contradicted his own teaching that ‘the value of experience is not in seeing much, but in seeing wisely‘. On the contrary, the author asserted that ‘Osler considered seeing much to be a requirement for seeing wisely’, and this was evident in the lengths to which Osler went to search for knowledge – from overzealous and occasionally covert autopsies, to the high number of training cadavers John Hopkins illegally acquired during his tenure. The author concluded that Osler should not be ‘the ideal to which physicians should aspire’ because he ‘reformed medicine by placing pathology at the foundation of clinical medicine’, and because his proposal to reform medicine confused professionalism and humanism‘, with the result that the latter lost out to the former (pages 14-23, 36 and 49-50).
A central theme in the book is the author’s assessment of the countless proposals that have been made to regenerate medicine, recommendations which he argued failed because they ignored the fundamental problem of medicine, that ‘we no longer see our patients as people‘. An example which illustrated this is the ‘Osler-style proposal for renewing medicine’ advocated by the physician and writer Abraham Verghese. The author rejected Verghese’s perspective that literary fiction and detailed physical examinations help physicians to ‘refocus‘ and understand patients; on the contrary, the author asserted that this proposition only ‘reinforces the role of physicians in contemporary life as the people with full responsibility for reading and interpreting the body’ and ‘for determining its meaning‘. The book similarly under-rated the role of evidence based medicine in helping to renew medicine, characterising it as a ‘state-of-the-art‘ way of seeing much which is ‘designed for the kingdom of quantification‘, but which does not relate to ‘the world of patients‘. The author particularly criticised evidence based medicine for its rigidity, arguing that ‘physicians…need to tinker with evidence-based scripts’ because ‘the ability to tinker, to adapt to changing circumstances’ is part of the ‘virtuous habits of attentiveness to detail and flexibility’. Following the same principles, the book also censured Schwartz Center Rounds as events where ‘the patient’s story is told by practitioners for the edification of practitioners’, but to the exclusion of the patient (pages 7, 52-63, 83-98, 126 and 64-66).
The author set out a detailed vision for renewing medical practice which emphasises nurturing virtuous physicians, and minimises the rules by which they practice. Noting that ‘physicians still perceive medicine as a calling‘, he regretted that the profession itself does not encourage them to view medicine as such – ‘a craft learned over time in a community of wise physicians’. In this regard, the author strongly advocated teaching physicians how to see their patients as ‘unique individuals‘, and how to attend to them as ‘fellow creatures‘. He further urged physicians to stop attempting to take ‘full responsibility‘ for the bodies and lives of their patients, but rather to develop a ‘more honest and bearable’ relationship that is more motivational than it is instructive. For this reason, the book advocated a collaborative ‘therapeutic alliance‘ in which the patient and physician mutually commit to the patient’s well-being by focusing on ‘patient-identified treatment goals’. To do this, the author urges physicians to develop ‘enough of a relationship’ with the patient, learning how to talk with, rather than to, them. He also encouraged physicians to adopt the role that is most appropriate to the individual patient, preferably as teacher, but also as captain, witness, or gardener; these are models that the author believed endow patients with control over the their bodies and lives, and therefore symbolise ‘the finest traditions of my calling‘ (pages 155-161, 4-5, 9, 25, 65-66, 109-113, 166, 174-175, 187 and 254-257).
This review does not do enough justice to the depth and extent of the contents of this book which is an all-encompassing critique of modern medicine, both at the patient-physician and organisational levels, as well as at philosophical, educational, structural, moral and even spiritual levels. It analytically examined hitherto sacred traditions and heroes of medical training and practice, and in the process advocated the re-evaluation of many of the pillars of modern medicine. The author’s criticisms of modern medicine appear largely valid, even if in some cases, such as the criticisms of Osler, and the high premium medicine places on pathology, seemed rather harsh. The book’s call to reappraise the physician’s perspective of patients is laudable, but it is clear that the impact of technology in modern medical practice, and the time and resource pressures that govern it, will be difficult to reverse. The book nevertheless points out the largely forgotten human foundation of medicine, to see the patient as a person; this simple and profound lesson is eminently achievable in the day to day affairs of physicians.
This very compelling book calls for a total reassessment of what it is to be a physician. The criticisms of the book all appear valid, even if somewhat generalised. The author has rightly identified the problems besetting modern medicine, and helpfully traced their roots. The ideal he advocates is worthy of reflection and consideration for individual doctors and teams to implement within their social circumstances. In this context, his recommendations about remodelling the patient-physician relationship, and adopting flexible roles as the circumstances dictate, without taking over control of the patients body, are invaluable. The subject of the book is pertinent to the whole of healthcare and I strongly recommend it to all doctors.
Publisher, Place, Year: Yale University Press, New Haven, 2016
Number of chapters: 17
Number of pages: 302
Star rating: 5