Dr Howard Spiro passed away on March 11, 2012. He was the founding chief of the Gastroenterology Section at Yale, a position he held from 1955–1982. During that time, he became widely known for his clinical acumen as well as his teaching style, abilities, and innovations. He was also a prolific writer; in addition to publishing numerous scientific manuscripts, he authored several books and was the founding editor of Journal of Clinical Gastroenterology. For these and related contributions, the American Gastroenterological Association awarded him with the Julius Friedenwald Medal in 2000. After stepping down as section chief, Dr Spiro founded the Yale Program for Humanities and Medicine, which provided a forum for examining the boundaries between medicine and the humanities and exploration of “the culture of medicine, medical care, and experiences of illness.” He remained active in this program until his passing. Therefore, it is appropriate that this, perhaps his final manuscript, bridges his two loves by discussing humanistic considerations in the doctor-patient relationship for an audience of gastroenterologists.
Michael H. Nathanson, MD, PhD
Professor of Medicine and Cell Biology
Director, Yale Liver Center
Chief, Section of Digestive Diseases
Yale University School of Medicine
New Haven, Connecticut
In 1947 when I graduated from medical school, so little was known about the inside of a cell that diagrams showed the nucleus floating in a barren cytoplasmic sea. In 2012, a similar diagram would mimic the Sargasso Sea, packed with seaweed connections.
Neuroscience has enormously clarified how the brain works, even though the mind and consciousness still escape explanation. Connections between hormones and neurotransmitters in the brain are so duplicated in the gut that some gastroenterologists have called our favorite organ “the second brain.” Whether that makes the dejecta cousin to thought, I dare not contemplate.
At a Yale gastrointestinal conference a while back, there was joy at the new endoscopes looking beyond the mucosa into the very cells, someday to record broken cytokines or maybe to mend a limping lysosome. Happy at seeing what had been so hidden, I was sad to think how far knowledge of the brain has surpassed comprehension of the mind.
That gap between brain and mind might be what makes study of science so different from contemplation of the humanities. It bears on the difference between Reason and Intuition. What Plato wrote about life and death remains as pertinent as last week's New England Journal of Medicine. Ideas from Athens and Jerusalem still today pervade our thinking and our purpose and into that trove, happily, pour the vast cultures of the Middle East, Asia, and Africa.
In the hubris of success, medical researchers look back only a very few years, maybe to 2001, but when we talk about falling sick or growing old, what Cicero, in his exile far from Rome, or Virginia Woolf, hiding in London, wrote remains as pertinent as yesterday's New York Times. Sophocles' drama of Philoctetes abandoned on an island with his stinking leg helps doctors to share the loneliness of the sick; Kafka's Metamorphosis lets us feel the torment of our body's betrayal.
The clergy are more generous to the past. When a study showed that red wine killed Helicobacter pylori, a Yale Divinity School professor boasted to me that was why St Paul advised, “Take a little wine for the sake of thy stomach.” “You see,” my friend exulted, “that St Paul really knew what he was talking about!”
Long-dead observers and thinkers remain as pertinent to human society as ever. Freud reminded us of the subconscious; modern theories about mind are influential even when we do not know their microscopic connections.
Reason rules the roost; current physicians are trained to think of the body as a machine to be repaired, people as collection of organs, and the mind as a secretion of the brain. Clinical practice has become a matter of following evidence, paradigms, and pathways. Interchange between patient and physician has shrunk to a series of questions and answers, pickled in electronic medical records.
Patients have disappeared into their functions, at least as far as the proverbial “laptop doc” is concerned. In current practice, what is displayed on images or by numbers dominates diagnosis, which leads to treating abnormalities that might not contribute to the patients' troubles. Gastrointestinal fellows reach for an endoscope in the uninsured, to whom they have hardly listened. Yet technologic advances have much strengthened clinical practice. Echocardiography displays sounds so precisely that even a doctor who is deaf can become a cardiologist.
Diagnosis is more than just scanning a deviation from normal. “The eye is for accuracy, the ear is for truth,” long my watchword, suggests how easier it is to look at computed axial tomography scans than to listen to the patients they stand for. I want to talk directly with patients. Every patient is different; every physician “takes” the history in a different way: the time of day, the blinking of the eyes, the pause between question and answer; those details influence how—and what—doctors hear. Just as listening for the whoosh of aortic insufficiency might vary with the ears of a cardiologist, so what the patient tells a physician can be as ephemeral as a butterfly.
I am an old man, trained in a distant era, and we elderly always think things were better when we were young. I might have been better then, but medical practice is far more accomplished now. Yet, our medical practice was more humane, physicians were more attentive to patients, and there was far less talk of money. Wrongly, my generation never talked with our patients about sex, politics, or religion, but we did look at the big picture and were satisfied with less than specific answers, and physicians mostly had a good time, maybe—my wife Marian reminds me—because we had never heard of “informed consent.”
Science has replaced religion; philosopher Paul Feyerabend has pointed out that “people are free not to believe in God, but they are no longer free not to believe in Science.” Evidence-based medicine has provided 21st century physicians our new faith in what has been proven by “double-blind” randomized controlled studies. Evidence brings blessed assurance of numerical truth, despite subsequent wrangles about appropriate statistical exegesis.
Some of us old folks wonder how reliable is the evidence-based medicine that now dominates medical practice; critiques of clinical reports come from statisticians in the search for mathematical certainty. Many clinical decisions have fuzzier borders than decimal points suggest. Deaf to their patient's words, clinicians treat the “average” patient by the rules.
Every action brings a response, and so during the past few years, renewed attention to the humanities, to novels, and narratives of illness have comforted clinicians. Narrative Medicine, as some call it, helps physicians to understand the human dilemmas that evidence-based decisions seem to avoid.
Some years ago I saw a young Hispanic woman whose chronic nonspecific abdominal pain had defied her doctors' depredations until the detection of H pylori. Through an interpreter, I learned that her husband beat her, she had had 4 failed pregnancies, her only daughter with spina bifida was confined to a wheelchair, and she was on welfare and could not work. She did have those antibodies to H pylori; they were new and in those days an exciting finding. However, as I listened to her story, I wondered how her doctors hoped to blame her dyspepsia on those tiny bacteria at home in her stomach.
Gallstones are wrongly taken to be responsible for much abdominal unrest. One out of 100 people with asymptomatic gallstones develop biliary colic each year. That first attack is significant; the 50% chance of a second attack makes it prudent to get rid of the offending gallbladder. However, let incidental “silent” gallstones show up on whatever image, and in 2012 the belly button will quickly be violated.
Suppose a college student with ulcerative colitis returns to tell his doctor how much better he feels after some pills were prescribed. His gastroenterologist might well sniff, “Great! Let's have a look!” Only after peering into the rectum once again will the doctor declare, “Oh yes, you are feeling better!” Happily, the doctor gets paid for that quick look far more than for listening to the boy's jubilation at feeling better.
I became a stomach doctor at age 24 and passed the stiff endoscopes we labeled “flexible” with enthusiasm. I gave up “doing procedures” at 40, when development of fiberoptic instruments warned that I might be spending more time with patients inaudibly at their backside than face-to-face listening to their stories.
I do not belittle the technologic advances that have much strengthened clinical practice. However, giving up endoscopy gave me the time to listen to the words as well as to the intestinal gurgles of my patients, many told me stories few others would hear, and I could put their images into context. Many of them complained of what I took to be “existential pain” that had no defining source aside from the sorrows of living. Abdominal pain that never wakes the patient up and that is just there all the time, unmoved by food or motion, is likely to have no discernable origin in the belly. Each new diagnostic tool uncovers some previously unseen abnormality that tempts the physician to remove or treat it, often unavailingly. The list is long, beginning with “antral mucosal prolapsed” of my youth and continuing all the way to sphincter of Oddi “spasm!”
Thinking about those stories led me back to the humanities. By the humanities we usually mean the visual and musical arts, literature, history, philosophy and theology, psychology, anthropology, and sociology. That is where empathy, humility, intuition, and hope, a few of the emotions that define our humanity, can remind doctors to treat the person as well as the disease.
Younger readers might smile at my insistence on the primacy of the person. “Pre-meds” are canny enough to recognize that majoring in molecular biology or genetics trumps study of English literature or philosophy for getting into medical school. Many studies confirm how they lose their empathy during the first years of medical training.
Science and technology underlie much that modern doctors do and more than we understand. In the 1940s physicians gave penicillin, which was newly discovered, to patients with pneumonia and watched the pneumonia vanish even if we did not know how it worked.
I am uncertain whether clinicians need to know how infectious agents, most recently the gonococci, marshal the genetic transfers to withstand new antibiotics. I am fascinated by the new knowledge about bacterial ecosystems and what they mean. However, I am sure that of the people who come to a family doctor's office, more require understanding of their lives than will benefit from scrutiny of their organs. How that will change with fecal transplants I do not know.
Modern medical practice relies on logic and reason and far less on intuition. I think of reason as coming from the brain and intuition as springing from the mind and growing with experience. Reason and intuition; one is visible, and the other more mythic. Current medical practice counts on reason alone. It is no longer acceptable in academic medical circles to talk about intuition, that other way of comprehending. In part, that is because the Enlightenment of the 18th century chose mathematics as the “science of sciences.” Clinical practice largely followed that route, which Isaiah Berlin labeled “The Scientific Fallacy,” the belief that all human problems can be solved by reason and logic. Medical students are taught to discard other ways of knowing, intuition that comes unbidden, without conscious thought, because it cannot be measured.
As the popular phrase puts it, we humans encompass body, mind, and spirit; our inner life counts. However, in clinical practice today science is the authority, even in human ways that depend on cultural choices that we cannot always explain, which might be one reason why reading the romantic poets so grabs many college students.
At Yale Medical School in the 1920s, Dean Milton Winternitz had a grand vision to bring Yale's law school and divinity school down to the medical school campus. His temple was to be the Institute for Human Relations, a grand vision incised in stone at the entrance to the medical school, but one that did not long endure.
With protocols from evidence-based medicine, robotic surgery, and genetically based therapies, current medical students ask what will be left for them to do as practitioners. I tell them that so far no computer has taken the place of a person who comforts the sick. The nurse practitioner who listens to the patient can comfort far more readily than any laptop doc. Clinicians more than ever must learn to act as mediators between the machines and our patients. To understand them, wider humanistic learning, more intuition, will be helpful.
The trouble is that 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, or they are embarrassed to try. Yet here is where a caring physician comforts so much more than a computer.
Restoring the patient-doctor dialogue is one goal of programs in the humanities: to pull the attention of physicians and nurses—all the caring professions—back to people, back to our patients—and to ourselves.
Physicians can look up to the heavens to find constellations or the Creator, or they can look down deep into the body to find cells and the twists and turns of amino acids. However, cytokines suffer no pain; lysosomes do not laugh. Physicians bring science to people who sometimes might need comfort more than cure.
This article was adapted from the Buffmire lecture, which was given on January 14, 2011.
Resources for Practical Application To view additional online resources about this topic and to access our Coding Corner, visit www.cghjournal.org/content/practice_management.
Conflicts of interest The author discloses no conflicts.
© 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.