Whenever I put a patient to sleep, all conversation, all culture, comes to an end. My job as an anesthesiologist is to take care of a patient’s organs, not to debate the meaning of life. That logic might well explain why most medical specialists ignore the field of medical humanities, now taught in almost half the nation’s medical schools. They think the field benefits primary care doctors, who spend a lot of time talking to patients, rather than specialists, who perform procedures and focus mostly on a few body parts.
Yet this is shortsighted thinking on the part of specialists, ironically abetted by medical humanities itself. The original purpose of medical humanities was to expand a doctor’s way of thinking in a general sense, by widening the doctor’s horizon. In some ways, it was to make doctors more thoughtful without their even knowing it. Over time, the field grew and divided into professional subfields, such as bioethics, narrative medicine, and social justice. Rather than help future doctors slowly develop through broad education, the subfields dispensed information and taught specific behaviors, making medical humanities a kind of profession in its own right. For example, through narrative medicine, doctors learned how to approach issues of death and dying, knowledge that prepared them for work on the cancer ward. When medical humanities also became an undergraduate field of study, disconnected from medical practice altogether, it drifted even further from its original mission.
The drift was understandable, as medical humanities needed to justify itself in a cash-strapped health-care system. This meant giving doctors useful tools. And indeed, bioethics, narrative medicine, and social justice in medicine are useful tools. Yet they mainly help doctors who talk to patients rather than those who work on body parts. A primary care doctor who reads a patient narrative of what it is like to live with heart failure may learn empathy, but the story is of no help to an anesthesiologist struggling to intubate a patient. According to the American Academy of Family Physicians, more than half of American doctors today are specialists.
To help all doctors, not just primary care doctors, medical humanities might do well to revisit its roots, which include the careful study of works of literature, art, history, and philosophy. Medical humanities should continue to dispense knowledge and teach technique, but it should also cultivate in doctors an interest in the humanities more generally, to help them learn the art of thinking.
Take, for example, a patient with a fever whom I put to sleep for abdominal surgery. During the case, the man developed a red rash. Against the background of his unaffected pale skin, the rash’s color stood out brightly as a healthy, ruddy pink. The trend lines on my monitors all read normal, and I felt something that I always like to feel, that all was well and everything was just as it should be. Yet something made me inspect the patient’s rash more closely. It grew purplish as my eyes moved in, while any one patch looked like tiny pinpricks of blood clustered together. What was going on?
Such passion for detail, once possessed mostly by lovers, detectives, and doctors, has waned among the last, who increasingly rely on machines to mediate between themselves and their patients. Machine data substitute for close personal inspections. A pulse oximeter, for example, spares me from having to regularly check skin color for cyanosis. A bispectral index monitor, which measures the depth of anesthesia, spares me from having to scrutinize a patient’s facial expression. Fortunately, reading literature has primed me to be cautious about machine data, which can sometimes exaggerate, distort, or suppress.
No single writer taught me this; I came to that kind of wariness by reading many writers—and many kinds of writers. Realist writers, for example, examine daily life, but they leave much about human psychology unexplored. They are like the doctor who studies a patient’s flesh but looks no deeper. Symbolist writers plumb the depths of human psychology to find the one eternal fact about people; to them, all drama and dreams derive from the same tragedy—usually death. Yet these writers ignore daily life too much. They are like the doctor who studies only vital signs—the indicators of life—to evaluate a patient, and nothing more. Ironists return to reality, but they concentrate it to a strong essence, ninety proof, to make it more entertaining. They are infatuated with real life, yet apply a microscope to reality in a way that produces a grotesque exaggeration, sometimes even venturing into the absurd—as, for example, Kafka did. In the process, they often lose touch with the larger reality of being. Absurdist writers are like the doctor who studies a patient’s flesh from only one inch away.
All novelists try to get closer to truth, and they do somehow, but perspective matters, and no one perspective accomplishes everything. It is the same for doctors. Relying solely on the machine perspective would have caused me to miss my patient’s diagnosis of early sepsis. At other times, however, the machine perspective is the correct one. Reading literature has helped to keep my mind nimble and my eyes always to be shifting their angle of view.
Reading literature also reminds doctors to keep their scientific systems of thought at bay. Many medical specialists are tempted to dwell in the world of pure thought, accompanied by their formulas and abstract classification systems. I myself have daydreamed of giving anesthesia remotely from a Caribbean island, applying my algorithms and equations, turning my precise dials and squeezing my syringes, while my patients lie somewhere in the universe, reacting ideally, as science and engineering predict they will, every time. But I know I would injure my patients if I gave anesthesia in this way, and for the same reason that a politician who consults only magazines, statistics, and committees makes lots of mistakes. The medical specialist, like the politician, must remain in constant contact with the living world to achieve anything.
Among procedure-oriented medical specialists, the rule during training is often “See one, do one, teach one.” First, you watch a procedure being done; then you do it yourself; then you teach it to someone else. It is how I learned.
Yet specialists can suffer from this approach, especially early in their careers, when they presume that a standard method for performing procedures exists. Slight deviations in patient anatomy, which exist more often than not, can easily throw such specialists for a loop. I have put 10,000 spinals and epidurals in people’s backs during my career, and no back was identical to another. Persisting with a standardized technique heedless of such irregularities not only leads to failure but can also be dangerous. I once saw a doctor mindlessly insert a spinal needle in the midline of a patient’s back, not taking into account the patient’s scoliosis, and almost hitting the bowels from behind.
Studying art taught me to think differently about procedures. All arts, including the art of medical procedures, are part of the art of design. Sculpture, painting, architecture, and medical procedures—all can be expressed formally in a linear drawing. And in a line—indeed, in just one stroke—we never find exactly the same thing. We find not only the limitations of the medium but also the limitations of the artist’s mind. We also find clues to the artist’s personality. Michelangelo’s forceful lines defined the essence of an object, revealing a sculptor more than a painter, while da Vinci’s lines were more subtle, suggestive, and dreamy.
Similarly, a well-performed medical procedure is more than just mechanical imitation. To master a procedure, a doctor must express his or her own peculiar vision of the world with needle, scalpel, or fingers. Finding the unique inevitable line with these instruments requires an exact touch and a quality of stroke that are at once something from nature and a revelation of the doctor’s peculiar way of feeling the human body.
Even when placing a simple intravenous catheter, for example, I am in a world seen by no eyes except my own, and felt by no fingers except my own. Sometimes the slightest blue streak in the patient’s arm is tenderly suggestive of a vein. While palpating the adjacent skin, I seize on momentary bumps and fix them in my memory. An exquisite sensitivity to the position of muscle and an acute feeling for the qualities of the skin’s texture dominate my mind. I feel the influence of the patient’s skin almost mystically. Then I penetrate the skin with the needle, not with trepidation but conviction, because hesitation increases the risk of failure, as when a cautious spearman misses the fish.
Some aspects of a medical procedure are schematic, but more often than not they demand a close rapport with a patient’s body part. Like artists, medical specialists must generalize some things and particularize others; keep an anatomical ideal in mind but also be responsive to variable physical structures and to their own nature. The study of art encourages specialists to put their own specific quality upon their handiwork, not just to mimic and repackage another doctor’s technique. This makes them better doctors.
I once relieved another anesthesiologist caring for a woman undergoing a hip operation. Before leaving the room, the doctor gave me a thumbnail sketch of the patient’s history, which included breast cancer. Everything seemed straightforward. An hour later, the patient began bleeding profusely from her hip. I rechecked the patient’s chart and discovered that her breast cancer had metastasized. Rather than the result of a fall, her hip fracture was likely a “pathological fracture,” meaning a fracture secondary to bone metastases, which typically bleed more during surgery. Fuming inwardly at the doctor who had failed to give me the full story, I rushed to place a second intravenous catheter and transfuse the patient.
Doctors, especially specialists, often rush through a patient history simply because they have less respect for history than they do for science. It’s not just that medicine is a branch of science. To them, science is concerned with advancing, with moving forward, with creating what has never existed before, while history is devoted to nothing more than restructuring what is old and recreating the past. What could be simpler, they think, than describing what has already happened? To them, the historian works like the guard posted outside the entrance of a nightclub to keep order: to ensure, in other words, that dynasties and countries don’t get mixed up, and that the famous people wait patiently in line for their ticket to immortality. History involves nothing more than managing traffic. Such a disdainful attitude makes medical specialists a bit sloppy when they craft or report a patient’s history—a growing concern as more doctors work in shifts and hand off care to others.
By reading history, I have learned that history and science are of equal importance. At the same time, history is not a science: It is not the accumulation of facts but the relation of them. Facts relating to the past, when they are collected without some intuition of possible meaning, some hunch, are merely compilations, and compilations are no more history than oil and canvas are a painting. In this respect, history is more like art. Yet when crafting a history, how much, and what, should the historian leave out? Historians face the same problem that bedevils artists: They never get it exactly right in every way. Patient histories, like portraits, can never be completely accurate, although doctors depend on them.
Understanding historians’ difficult task has made me more cautious when giving and receiving a patient history. Doctors think their world is a scientific one of knowledge, but in reality, belief precedes knowledge. For doctors to function in a busy practice, they must believe before they think—they must believe the histories that are fed to them—as no doctor has time to question every patient history or scientific study that guides his or her work. Hence, the art of thinking in medicine is really the art of believing—correctly.
During a medical emergency, the humanities are of no use to the specialist, in part because the problem is technical but also because there is no time to reflect. For a doctor caught up in an emergency, ferocious activity submerges all thought; at each instant, thoughts pop up and instantly vanish. During an airway emergency, for example, when a patient is close to suffocation, I sometimes feel as if I am in a kind of dream, barely understanding what is happening.
Only later, when reconstructing the actual event and thinking through the full terror of it all, does the doctor compose a story and dwell on it. In one extreme example, I know an anesthesiologist whose patient died in the operating room. Although her patient died once, the anesthesiologist puts herself in the place of her patient and replays the scene over and over in her mind, dying a thousand times.
In such cases, the humanities, especially philosophy, can help a doctor. It is not the content of any particular philosophy that helps. On the contrary, many philosophies preach the futility of life and how the vast universe brings people joy and sadness according to laws over which they have no control. For the shell-shocked doctor reflecting on some catastrophe, such philosophies do little to slow the hemorrhaging of self-confidence or ease the persistent feeling of terror. Instead, philosophy as a whole helps doctors by putting the act of thinking itself in perspective.
The word philosophy means “seeking wisdom.” To seek something infers the possibility of finding it; the person who is seeking has hope. Doctors give patients hope all the time, and most patients like to think optimistically about the future. Yet doctors can give hope only if they have it themselves. The problem is that doctors, often being overly intelligent and tending to think too much about themselves, risk trapping themselves in self-destructive modes of thought after a medical catastrophe.
Philosophy’s message to doctors who have suffered a catastrophe in their practice is to let the life force within them take its natural course. This allows them to forget over time, to resist dwelling too much on the disaster. Feelings of guilt and sadness are never useful to a doctor. One must start seeking again, start hoping again, and get back to work.
Human beings learn to talk before they learn to think. Thinking is an advanced skill. It is not synonymous with exact knowledge learned from books. It develops slowly, through general education.
Gradually, almost imperceptibly, people educated in the humanities widen their intellectual scope and learn how to think. They go from being technicians accustomed to managing material magnitudes and formulas to being practitioners of the art of medicine, capable of responding to the challenge of the living world, where much takes place under novel conditions. True, a medical specialist remains a technician of sorts—the technician of a body part. But after being exposed to the humanities, he or she also becomes a technician of general ideas. Those ideas are what keep the specialist from being overthrown by life when events unfold in unpredictable ways.
Medical specialists who are just technicians of a body part are dangerous because they do not believe they are limited. They carry inside their minds a precise map of the technical system they work with; they are perfectly at home among their dials, tubes, and switches when they care for real patients. Because they focus more on a body part than on talking to human beings, they believe that their technical system can always get them through.
This makes them overconfident. They forget that a body part is more complex than a transistor or a computer chip, and that it does not exist in isolation. In physiology alone, everything is coupled and connected. Living tissue itself is natural, and therefore unpredictable. No inner map will lead by itself to sure success in medicine. Reason alone may guide a technician, but it is insufficient to guide a doctor, even a specialist. Specialists need the medical humanities to remind them of this—and to teach them the one thing that, alone, can make them better doctors: the lesson of humility.