Several years ago, I was involved in a case that illuminates the difficult position many doctors today find themselves in. The patient was pregnant, close to delivery, and experiencing dangerous declines in her baby’s heart rate. She had been on a blood thinner, which kept me, the anesthesiologist, from placing an epidural in her back. She also had strange airway anatomy, which would make it a struggle to put her to sleep quickly if an emergency cesarean section became necessary. I advised the obstetrician to perform an elective cesarean section now, in advance, while we had good working conditions, and not to wait for an emergency, where time is of the essence, and where the delay needed to induce general anesthesia might seriously injure the baby.
The obstetrician grew quiet. She seemed to descend within herself, in that lonely region of stress and strife where people feel themselves to be in an untenable position. Several things worried her, she confessed. First, hospital management had already warned her that her high cesarean section rate made her an outlier among her colleagues, which put her job at risk. Second, the baby’s heart rate did not quite meet the criteria for when to perform a cesarean section. True, the current situation was unfamiliar and unforeseen; then again, she wondered, would hospital management, let alone the malpractice lawyers, accept that excuse? Third, she wondered how to persuade the patient to have an operation that her own rules seemed to advise against.
The changing work environment in which many doctors practice medicine leads to such moments of uncertainty—and all but guarantees that they will occur more frequently. As more doctors work for large companies, they have bosses they must answer to. Rules for how to practice medicine have multiplied exponentially, and their bureaucratic enforcement makes doctors afraid to violate them. With science forming the bulk of their medical and post-graduate education, doctors also feel bewildered when faced with questions that touch on the moral, the political, and the philosophical.
During the last fifty years, the field of medical humanities—particularly the subfields of bioethics, narrative medicine, and social justice—has tried to help doctors deal with some of these issues. But the new environment in which doctors work is so radically different from what it was a few decades ago that the field as now conceived has little to offer them. Worse, medical humanities veered off course during this same period, focusing on patients more than doctors, and making it even less relevant to doctors’ professional lives.
Doctors need a medical humanities that does more than just help them see health and disease through a patient’s eyes. They need one that helps them look into their own minds, that gives them models of order and clarity with which to understand their own thought processes, and that helps them maintain their own equilibrium when dealing with bosses and bureaucracies.
The Great Transformation in Medical Practice
Around the mid-twentieth century, the division between science and the humanities gave rise to a new sensibility. Intellectuals worried that humanities people knew too little science, but worried less whether science people knew the humanities. C.P. Snow’s 1959 lecture “The Two Cultures” exemplified the new, science-centered sensibility.
The new sensibility had few immediate consequences for doctors. In those days, physicians saw themselves less as scientists and more as artists who used science to understand the human condition, which cannot be reduced to universal principles. Another popular model for the doctor was the navigator on the seas who must work with limited empirical knowledge and choose a course with some doubt. But gradually the new sensibility seeped into medicine. In 1964, the NIH created the Medical Scientist Training Program (MSTP) to formally train future doctors as research scientists. These amphibious creatures were half inside, half outside medicine, and in spirit moved away from traditional medical practitioners and toward scientists. I observed this in medical school during the 1980s, when some of the MSTP students who trained alongside us would laugh at the regular medical students for their lack of scientific rigor when crafting experiments.
Over time, the sensibility also affected everyday medical practitioners, who increasingly gave short shrift to the humanities. During the 1970s, pre-med undergraduates still had to take a year of English literature to apply to medical school. Gradually that requirement was watered down, with some medical schools accepting mere proficiency in the English language as a substitute and others accepting a year of social science as an alternative (even though the social sciences are not the humanities}. Still others dropped the requirement altogether. Sometimes, the new dismissive attitude toward the humanities was less subtle. In 1980, during my Tufts University medical school interview—a school that prided itself at the time on training clinicians over scientists—my interviewer laughed at me for having taken so many history courses, insisting that such courses were a waste of time for a clinician.
During the next few decades, the humanities shrank in relevance for doctors, until doctors knew no more of the humanities than the average person was expected to know. Doctors did not forbid the humanities; they simply saw no point to it. Whenever a problem arose in medicine, the solution was thought to lie in more science and technology. But without a humanities background, doctors found themselves lacking the intellectual resources for answering ethical questions posed by the new science and technology.
A second source of confusion for doctors arose concurrently. During the first half of the twentieth century, doctors had rules and guidelines for how to practice medicine, yet much in a patient encounter was still left up to the individual physician’s judgment. The “bible” for many doctors during this period was the Merck Manual, a publication updated every few years that listed the various diseases and the drugs that might be prescribed. At mid-century, more detailed how-to books became available, yet many doctors wanted more guidance.
The system delivered. Over the next forty years, medical journals and textbooks published algorithms covering practically every medical condition. Companies that employed doctors often gave each new hire their own “how-to” manual. The algorithms typically came in the form of vector diagrams that forked multiple times.
Doctors generally liked these algorithms because medical information and therapies grew rapidly each year. But gradually doctors sensed they were losing control: The decisions they made no longer belonged to them but to the crowd—to the crowd of data compilers who crafted the algorithms. Malpractice lawyers also studied the algorithms, and doctors feared that deviating from them would set the whole legal system in motion against them. Meanwhile, government and non-governmental agencies harnessed the power of algorithms to produce “promising practices,” “best practices,” and “evidenced-based practices,” to steer doctors’ decision-making down pre-determined paths.
In this sense, medicine was simply following the path of evidence-based practices laid down by a variety of industries, from agriculture to manufacturing. But algorithms do not work in medical practice as well as they do in industry. Patients are rarely so predictable. Yet without the humanities, how could doctors understand why their own rules had risen up against them? On what philosophical basis could they protest the new situation and emphasize intuition, “practical wisdom” or individual judgment as alternative modes of thinking? Without knowing the humanities, doctors could not see through the walls that imprisoned them.
A third change in the doctors’ work environment compounded the problem. As more doctors worked for companies, not only did they have CTOs (chief technology officers) who enforced the algorithms, but also CFOs (chief financial officers) who pushed doctors to factor in cost when making decisions. In 1983, three-fourths of all American physicians were self-employed. Today, more than three-fourths of all American physicians are employed by corporations that are driven by the imperatives of quarterly earnings reports and return on investment.
True, most self-employed physicians in the past also wanted to make money. But more often than not they tried to conceal the money-making urge from themselves; sometimes only at the bottom of their consciousness would they admit to it. At the very least, their consciences often checked them and gently repressed the profit motive within them so that it wouldn’t get too out of hand. But the ethical system that physicians work with today is of a highly commercial type. The doctor does not become dishonest, but is more commercialized than before. A health-care company, like any company, lives to get, to come out of every transaction with more than it gave, and doctors feel this ethic all around them, daily, as when they are encouraged to nickel-and-dime patients—for example, by charging a flat (and high) fee for a mere three-minute telemedicine interview.
There is always an element of overreaching and outwitting in business. It may be refined, it may be dignified, but it is there. It is not cheating; but at the same time it is not the professional ethic that many doctors imagine themselves working under while practicing medicine. Yet doctors hesitate to fight back. Their employers can replace them if they cause trouble. Worse, their employment contract often has a non-compete clause, forcing them to leave town if they separate from the company. The CFO and CTO swim naturally in this new, sharp business environment that plays to win; doctors, on the other hand, feel alone and adrift in this world. Without the humanities to explain their situation to them, to tell them what a doctor once was and might become, doctors see no path forward and resign themselves to the dictates of the commerical ethos.
The Medical Humanities Solution
Bioethics emerged first in the medical humanities, as a solution to the problem of doctors growing too science-centric. I call it medical humanities 1.0.
To the extent that bioethics existed during the first half of the twentieth century, it was called “professional ethics,” and was viewed as a natural part of a broadly-educated doctor’s skill set. But as their familiarity with the humanities waned, doctors needed help.
At first, doctors thought they might keep bioethics under their control. The new field can be traced back to 1966, when anesthesiologist Henry Beecher wrote an article about the failure to inform patients of the risks involved in experimental treatments. The article was published in a medical journal with mostly physician readers. But both physicians and non-physicians quickly understood that the medical profession lacked the humanities background for dealing with more complex ethical issues. In 1969, the Hastings Center was established, followed in 1971 by the Kennedy Institute at Georgetown University, both staffed primarily by non-physicians, including philosophers, sociologists, lawyers, and theologians. Such institutions helped guide the development of bioethics. By the early 1980s, these new bioethicists controlled not only the public discussion on relevant subjects but also the discussion within medical schools.
But bioethics had limits. Rather than help doctors make decisions in everyday clinical practice, it dealt more with unusual situations, such as the definition of death. More important, as bioethics came under the control of non-physicians, a tendency arose within all medical humanities to emphasize patients more than doctors. Early on, this emphasis translated into a focus on patients’ rights. But in the years to come, that emphasis would cause medical humanities to overlook the doctor’s evolving work conditions and the change in the doctor’s inner world that went along with it.
This became evident in late 1980s with the second iteration of medical humanities: narrative medicine, or what I call medical humanities 2.0. Narrative medicine’s purpose was to help doctors absorb and interpret the stories and plights of patients. It grew out of the feeling that doctors never really lived among their patients, never shared in their lives and thoughts, but, instead, wrongly dwelt above them, in the clear, still ether, in the ivory tower of science.
Narrative medicine highlighted some useful issues relating to patient care. Once, while in medical school, I was reprimanded—and rightly so—for relaying a patient’s history as merely a list of symptoms. I failed to give the symptoms context and tell the patient’s story. But like most young doctors, I learned to do better through experience. Even if it had existed at the time, narrative medicine would have been unnecessary. Indeed, many doctors adopted an attitude of semi-indulgent contempt toward narrative medicine, thinking it lighted up a few problems but never actually solved any important ones.
Some business people liked narrative medicine more than doctors did because it helped facilitate a shift in the way the health-care system viewed patients and doctors. This included turning patients into consumers and doctors into service providers. “Patient-centered care,” in which the patient rather than the doctor calls the shots when deciding treatment, exemplified this thinking, as narrative medicine’s agenda shares much with the commercial belief that “the customer is always right.” Some doctors, in turn, grew disturbed, as patient-centered care awarded them responsibility without authority—a legally precarious situation to be in.
In the 2010s, medical humanities entered its third iteration as a sort of indoctrination into social justice—what I call medical humanities 3.0. Tracking larger political trends, social justice in medical humanities focused on the feelings and concerns of marginalized patients. What doctors felt and thought grew even less important. In some ways, it became irrelevant and was even sometimes dismissed as betraying unconscious bias. For example, I once observed in a public forum that socioeconomic class rather than race accounted for some of the high mortality rate seen among African-American obstetric patients. Patients in the low-income group (of which African-Americans are over-represented) have a higher rate of morbid obesity, raising the risk of obstetric complications. They are also less likely to keep their pre-natal appointments, thereby raising the risk of their going into labor with severe pre-eclampsia. I was reprimanded for my political incorrectness. I was not alone among doctors who found that this form of medical humanities unhelpfully intrusive. Added to the burden of their changing work environment, it forced them to be politically oversensitive, to speak cautiously, and to be constantly on alert for the reproving eye.
The three iterations of medical humanities have failed to help doctors practice medicine in their new work environment. They have been domininated by a concern for what patients think, showing little for what doctors do. A new iteration of medical humanities is needed.
Medical Humanities 4.0
Most doctors have neither the time nor the interest to pursue a serious humanities education, and while some pre-med students major in a non-science, much of the humanities today involves the teaching of ideological constructs rather than real knowledge, thereby creating partisans more than independent thinkers. A clinical humanities education must be tailored for time, given doctors’ proclivities, and entail reading not for the sake of learning, which many doctors dislike, nor for the sake of politics, which many doctors disagree on, but for the sake of life. Its goal must be to help doctors think past the walls in today’s work environment that hem them in. Four areas of study are essential.
The first area would focus on the relationship between mental health and scientific medicine. Many largely psychological dimensions of human experience, such as unhappiness, anxiety, pain, loneliness, and spiritual confusion, have been brought into medicine’s orbit, compelling doctors to look upon them as engineering problems that demand a physical remedy. Some doctors sense over-simplification and exaggeration in all this, but they lack the humanities background to think these matters through. Clinical humanities would introduce doctors to the mind-brain debate, and to what philosophy and literature have to say about everyday emotional and existential experiences, thereby giving doctors the knowledge and confidence to make more nuanced clinical decisions.
The second area might examine the scientific method, its role in extracting rules and algorithms from “big data,” its defects, and the tendency among physicians to take its limitations for the limitations of reality. Clinical humanities will help illuminate alternative modes of thinking, such as intuition, practical wisdom, and judgment, thereby giving doctors the confidence and intellectual resources to resist the gravitational pull of rules and algorithms.
The third area would explore the “good life.” In medicine, there are always trade-offs—risks and benefits—when treating people. People are different; everyone has his or her own opinion about lifestyle and even addictive behavior. Who decides the optimal balance? Science? The company? The uninformed patient? The doctor—and if so, on what basis? Clinical humanities will expose doctors to the history of such questions as well as the philosophies that have tried to answer them, thereby giving them a foundation other than personal bias.
The fourth area will help doctors answer the question, “What is a doctor?” The crisis that doctors face in their new working environment is ultimately a crisis of identity. Doctors no longer know who they are. They no longer know, for instance, if they are more than scientists or technicians. They no longer know if they are mere allies of patients or something more commanding. All is at sea in the sphere of their minds. Their doubts haunt them even when they make minor decisions. The situation will only grow worse with the next forward and downward change in medical practice: the coming of artificial intelligence. Clinical humanities will give doctors a better understanding of who they once were, are now, and might become, thereby stabilizing their sense of identity.
Doctors without the humanities live like blind people in a large room, aware only of what comes in contact with them and unable to see the general aspect of things. Situations appear before them in an unconnected and undirected ways. Problems seem to come from nowhere and get resolved one way or another, but without the physicans' clear understanding of the reasons behind the available options. Clinical humanities seeks to restore doctors’ sight, to focus on their problems as much as on the problems of patients, and to give them more control over their professional lives in a world that has grown strange and unfamiliar to them.