Who’s for Tennyson? The case for language and literature in medical school

By David Woods, PhD, FCPP

In his impious 1911 glossary The Devil’s Dictionary Ambrose Bierce defined a physician as “one upon whom we set our hopes when ill and our dogs when well.”

But in today’s medicine, our hopes are more likely to rest with an array of sophisticated technologies and gadgetry, rather than with a human being. Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine, says: “This technology has become a religion within the medical community.  It is easy to lose sight of the fact that still, in the 21st century ... 80 to 85 percent of the diagnosis is in the patient’s story.”

Yet many physicians today lack either the skill, the time or the inclination to listen to that story – a talent that used to be called bedside manner. This is a shame because of the four elements in communication – speaking, reading, writing and listening – listening is learned first, is used most through life and is taught least through all the years of schooling. Yet deficiencies in listening and the ensuing failures of communication are a major source of wasted time, ineffective operation, miscarried plans and frustrated decisions. In medicine, they can also be a source of error and litigation.

But according to the New York Times “It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: Narrative Medicine.” This is part of a growing trend towards exposing medical students to the humanities in much the same way as Drexel provides such courses to first year engineering students.

Narrative Medicine’s founder, Dr Rita Charon, teaches such a course at Columbia University’s medical school. In the 19th century, she says, doctors carefully and humbly visited with patients – listened to them; and not just with a stethoscope. Parenthetically, the inventor of that instrument, R.T. Laennec, required his medical students to take exhaustive notes after seeing a patient. Dr. Charon believes that medicine has been struggling to come close to the patient ever since that time. “Medicine,” she says, “is beholden to the singular experience of individual patients; we’ve always known this. But it’s been eclipsed by a heady optimism that because we understand organ systems and molecular biology we understand the patient.”

If you listen to patients’ lament, she says, “It’s not that ‘my doctor can’t open my stent;’ it’s that ‘my doctor doesn’t listen to me.’” Not that Dr Charon has much time for bland exhortations to create a more caring and empathic medical profession. “What’s needed,” she says, “is the prescription; the How.”

And that’s what Narrative Medicine is about: reading, writing, perceiving – paying attention. Since 1982, Dr Charon’s students have been analyzing in literary terms that which they hear and read. It has to do with eliciting nuance and subtlety.

She emphasizes that this is no soft option course. Not only are Columbia med students required to take graduate level humanities courses, the material itself is presented in a highly rigorous and disciplined manner. Says Dr Charon, who is an internal medicine physician who also has a doctorate in English: “When I teach Henry James here, I do so as I would in the English Department.”            

Dr Charon’s group also produces a seminannual journal, Literature and Medicine, which is published by Johns Hopkins University Press. And Oxford University Press  published her book Narrative Medicine: Honoring the Source of Illness.

Another well-known exponent of communication skills for medical students was the late Norman Cousins. Cousins, who wrote Anatomy of an Illness, the story of his diagnosis and treatment for ankylosing spondylitis, was an eminent journalist who went on to teach medical students at UCLA. In an interview with him some years ago, he told me that he’d developed a survey of 500 patients. One of the questions was: ‘If you’ve ever changed doctors – why?’ “That really got the attention of the students,” he recalled.

Cousins went on to say that “What is required {of a doctor} is the deepest possible understanding of what the patient is talking about. Respect for the patient” His survey yielded such responses as ‘He was a very competent physician but he really didn’t know what my problem was;’ or ‘I admired him as a doctor but I had no confidence in him as a human being.’ Cousins’ conclusion: It’s the style of the physician, not the competence of the physician, that is the yardstick people use for keeping or changing their doctors.

Cousins further believed that “medicine begins with science but treatment of human beings involves artistry. Physicians need to marry art to science.” Moreover – shades of Narrative Medicine – Cousins told me that “novelists portray the physician not just as a prescriber of medicaments but as a symbol of all that is transferable from one human being to another.”

All of this is not simply to create a new layer of kinder, gentler doctors ... or to graft some Gray’s Elegy onto Gray’s Anatomy. It’s to rediscover a fundamental part of the diagnostic and therapeutic process, one that will make the patient’s medical encounter more productive and less frightening. ‘Doctorspeak’ too often means jargon that’s incomprehensible to patients, who may not be at their receptive or emotional best. And the impersonal “put the emphysema in the other ward and bring the prostate biopsy in here” doesn’t help. Nor does the absolving “We” -- also favored by royalty and editorial writers -- as in “How are we, today?” or “We see a lot of that.”

Novelist and psychologist Liam Hudson says there’s a “crisis of intelligibility” among scientists, and notes that the truth can best be grasped by prose that is itself vigorous, disciplined, and plain. Noting that scientists are barely able to utter a sentence that does not include the key words situation, interaction and role, Hudson says that by contrast the business of writing a novel or a poem is one of highly-wrought discipline. What lies between scientists and their subject matter, he says, is an inadequate grasp of the English language. Their grasp can be tightened by reading, interpreting – and understanding -- the great writers.

Tennyson, anyone?

You can reach David Woods at hmi3000@comcast.net or at www.davidwoods.info

Walter Tsou, MD, MPH

By David Woods, PhD, FCPP

 
Despite the high-profile positions he's held as Health Commissioner of Philadelphia and as President of the American Public Health Association, Dr Walter Tsou is a pretty unassuming guy. An adjunct professor of family medicine and community health at Penn, he wears his erudition and his accomplishments lightly.

But that doesn't mean he isn't a passionate proponent of public health and a stalwart advocate for a single-payer healthcare system, serving on both the National Board of Public Health Examiners and national Board advisor to Physicians for a National Health Program (PNHP).

At 60, he now focuses mainly on family life with his wife Jean Lee, a nephrologist, and his 13-year-old daughter, Casey, who definitely won't go into medicine, she says, because she hates the sight of blood. Coming relatively late to family life Walter notes wryly that he gets to read Modern Maturity and Parent magazine

Asked what’s given him the most professional satisfaction he unhesitatingly points to the hands-on practice of public health. A particular joy was when he served as deputy director for personal health services and medical director of the Montgomery County Health Department and helped to stamp out hepatitis B among  local schoolchildren. He also appreciated the autonomy that that job gave him, in contrast to his role as Philadelphia Health Commissioner where he came up against Mayor John Street’s bureaucracy.

Walter’s medical degree is from the University of Pennsylvania and his MPH from Johns Hopkins School of Hygiene and Public Health. He started out in internal medicine, but wound up working in a public health clinic, and the rest, as they say, is history.

As for the Affordable Care Act, while he acknowledges that its introduction has been far from stellar, it's also not a simple matter to launch such a convoluted software program. In fact, he says, a single-payer system would not only be more streamlined but would encourage doctors to join organized medicine.

Of his rather low-key manner, he says that if you preen too much you can become a target. People like to shoot at targets, he says, and this is especially true for public health physicians who are highly visible. If they’re seen munching on hamburgers, drinking, or lighting cigarettes someone’s sure to jump on them.

One public health issue that could find Walter in the cross hairs is fracking. He believes that the current methodology which involves millions of gallons of water  creates a health risk. “We have to be careful,” he says, “and look to less dangerous ways of extracting shale.”

If the government has difficulty in introducing so-called Obamacare, is there any hope that it could run a national health program? Well, PNHP has some 18,000 members, and thinks it can. And Walter Tsou agrees, noting that the US is the only advanced country that doesn’t have such a program. The barriers, he believes, are the strong and well-heeled lobby groups in the pharmaceutical and private insurance industries.

Both Walter and his wife are of Chinese extraction and he serves on the board of the Asian Pacific Islander American Health Forum. Among his many accolades is the Public Health Recognition Award from the College of Physicians of Philadelphia, where he is a trustee. He believes that the College is a wonderful source of both social and educational activity. And you may see him at either. Just don't expect him to preen. He's better at asking questions than answering them … noting that his Myers-Briggs score suggests he would have made an  excellent journalist.

Since he and Jean enjoy the theater, ballet, and movies maybe Walter’s next career will be as an arts reporter or movie critic.

But he won’t tell everyone.

You can reach David Woods at hmi3000@comcast.net or at www.davidwoods.info

The Future of Medical Publishing

By David Woods, PhD, FCPP

(excerpted from a speech to students at Jefferson's College of Graduate Studies.)

Commenting on the future of anything is a mixed blessing. On the one hand, for an editorialist it offers an irresistible combination of temptation and opportunity; on the other hand, one is mindful of the many who have upended themselves memorably on the banana peel of prediction.

For instance, in 1800, Thomas Malthus, a practitioner of what later became known as "the dismal science" of economics, famously foretold of a world population imminently to be extinguished by its inability to feed itself. Today, a senior fellow of the Hoover Institute claims that "the entire population of the world could be housed in the state of Texas, in single-story houses -- four people to a house -- and with a typical yard around each home."

This assumes, of course, that you could persuade them all to move to Texas.

In 1943, Thomas Watson, then-chairman of IBM, stated confidently that there was a world market for about five computers. And C.P. Scott, crusty editor of the (then Manchester) Guardian is said to have snorted: “Television? The word’s half Greek and half Latin: no good can possibly come of it.”

No wonder Yogi Berra vowed that he would predict anything except the future.

Since Thomas Wakley published the first issue of the Lancet in 1823 – as he put it “to put an end to mystery and concealment” in the world of medicine -- the sum total of medical knowledge has increased explosively (today there are some 25,000 biomedical journals) and the speed at which communication is achieved has been even more dramatic. In Wakley's time, the speed of communication was no faster than a human or a horse could carry it. Today's communication is about two-thirds of a billion miles per hour. The good news is that that's as fast as it can go.

Unless, of course, Einstein was wrong.

The bad news is that costs have no such limitations. While Wakley’s Lancet sold for sixpence, average annual subscription prices for medical periodicals surged from $51 in 1977 to a whopping average four-digit price in many instances today. No wonder Cornell University  decided to review and severely prune the $1.7 million a year it was paying mega- medical publisher Elsevier for some 930 science journals.

In his book 'The Inarticulate Society', Tom Shachtman says that Americans today watch 1,500 hours of television a year, which means about 50 days a year; or, if we extrapolate a bit, roughly nine years by the time they reach 65 if they haven’t expired earlier from boredom. By contrast, they spend a combined total of only 290 hours reading newspapers and magazines. Part of this decline in literacy, says Shachtman, is the chasm between the literate-based and oral languages. He refers to a computerized scale of comprehension skill in which a "level of difficulty" of an article in a scientific journal, Nature, rates 58.6 units, compared with a sample of Time magazine at 6.8 and of The National Enquirer at minus 10.3. He then goes on to note that "knowledge derived from {print} tends to remain more detailed, to stay with us longer, and to be more broadly based than what we receive from television." Perhaps that's why the three principal medical television companies have ceased to exist in the past couple of years.

Neil Postman, professor of communications at New York University, points out that the process of reading encourages rationality. Postman -- surely a felicitous eponym for the bearer of such an epistle -- says that a printed page containing a narrative or argument that unfolds line by line encourages a more coherent view of the world than does a slambang broadcast of quickly changing, high-impact images.

In any event, there's a wonderful invention known as the Box Of Organized Knowledge. It has no electrical circuits or wires or mechanical parts, can be used anywhere, and consists of a number of sheets of paper bound together. The symbols on each sheet are absorbed optically and registered on the brain. This phenomenon is known by its acronym B.O.O.K.

The Economist, in a special report on the future of medicine, noted that doctors are finding it hard to absorb ever more information, and that American doctors typically spend no more than three hours a week educating themselves. And for most of them, the report says, applying the knowledge gained from reading journals has become as much an art as a science. The information can often be conflicting and few doctors have any idea how to resolve such conflicts. Not that this is a new phenomenon. More than a century ago Sir William Osler noted: "It is astonishing with how little reading a doctor may practice medicine, but it is not astonishing how badly he may do it."

What does this mean for publishing? It means a whole new set of opportunities. Healthcare professionals are avid for management information, and  customer service and legal and ethical issues are all assuming new significance; new technologies need to be explained; information technology has to be demystified. It’s hardly surprising that an estimated 2% of our $2.5 trillion a year healthcare system is now spent on consultants trying to figure out, and explain, what’s happening! For medical writers the opportunities are huge. Not only in interpreting the enormous and complex advances in medical science, but also in exploring and clarifying the healthcare delivery issues that affect all of us: Affordability is perhaps the main one. But also the need for ‘wiring’ healthcare; the aging population; increasingly sophisticated (and expensive) technology; malpractice and medical error; consumer power; quality and consistency of care; the 44 million or so uninsured Americans; the threats posed by biologic, chemical and radiologic weapons; re- thinking the way we train health professionals  and the continuing, nagging issue of what former Penn professor of medicine the late Dr. Bill Kissick called “Infinite needs versus finite resources.”

So with paper costs rising, journal advertising declining, subscription prices forcing libraries -- and individuals -- to cut back on purchases but still to demand the best and most current information, is the way to do it an electronic way. A superhighway?

Well, radio existed for 38 years before it had 50 million listeners; television took 13 years to reach that number; the Internet got there in just 4 years. Today, the overwhelming majority of US physicians access the Internet… with medical libraries and publishers' sites ranked highest among doctors who use the web for professional reasons.

To be sure, the Internet is more quirky and less linear than print. Whoever said that freedom of the press is greatest for those who own one was unwittingly prescient. Traditional publishing is an ex-cathedra affair, top-down, hierarchical. Electronic publishing is essentially egalitarian. Not only that, but in the electronic age, publishers may not be the only ones doing the publishing. Universities  may be the sleeping giants of publishing with the World Wide Web having turned every university into a publisher and every faculty member into an author; after all, the University's business is knowledge creation, transmission, and management.

And incidentally, anyone who enters chat rooms on the Internet will readily see that it's only a matter of time before we return to grunts and hieroglyphics. In medicine, where clarity and simplicity in communication are vital, there is a crisis. Illegible handwriting is one thing; unintelligible speech and prose are quite another.

 In sum, I see a synergistic broadcasting of information through a variety of media… with quality and relevance and credibility of the material being the principal factors governing the user's choice of medium. In fact, the British medical Journal suggests an amalgam of short print articles hitched to a more detailed version of the same thing online. The Journal also whimsically leans on the Simpsons to illustrate changes in medical publishing. After noting that such publishing is changing dramatically because of many forces, the editors posit four possible futures: In the wise (Marge) world, academics innovate and publish primarily on the web, not in journals; publishers must publish large numbers to succeed. In the lazy (Homer) world, publishers adapt to the electronic world and continue to publish research. In the well-informed (Lisa) world publishers have largely disappeared and communication takes place mainly through global electronic conversations.  And in the streetwise (Bart) world, publishers have largely disappeared, and large organizations have become the main purveyors of research.

As the Association of American publishers puts it: " there are some who will rightly conclude that the changes in medical publishing are so enormous, and the sociological  adaptability lacks so far behind, the business of print-based publishers will continue to be robust way into the 21st century.

Dr. Lucy Rorke-Adams: A professional lifetime in neuropathology and it just keeps going

By David Woods, PhD, FCPP

The Children's Hospital of Philadelphia has hundreds of employees. At 8 o'clock in the morning it sometimes seems as though all of them are coursing through the hospital's entrance doors at the same time.

Up on the 5th floor though, in the pathology area, things are appropriately more tranquil. Dr. Lucy Rorke-Adams had sent me an e-mail confirming the 8 AM time for our 2nd interview. It came from her office at 4:47 AM -- her usual time of arrival at the hospital, where she is head of the department of neuropathology.

She drives her Infiniti the 17 miles to work from her home in Moorestown, New Jersey, a town that Money magazine rates as one of the best places to live in the United States. Through it runs the King’s Highway, charitably named for King George III.

A petite and trim 84, white coated and perfectly coiffed, she greets a visitor to her small book lined office where can be heard the strains of classical music from the Temple University radio station, which served as background to our hour- long discussion. She describes her evident youthfulness to hard work, keeping up her interests, and a sense of curiosity. In fact, she attributes her strong work habit to several of her forebears.

When she's not hard at work though, her interests include music and reading; in fact, she describes herself as a ‘bookaholic. ‘As well as an entire floor-to-ceiling wall of medical texts in her office she has a substantial library at home. Reading for pleasure includes mainly history and biography… but she’s also a big fan of detective stories, especially those involving Brother Cadfael, the fictional 12^th century Welsh monk and sleuth.

Her musical tastes run to opera. She’s a particular fan of Verdi, and a regular at the Metropolitan Opera.

“But I don’t watch television,” she says, “because I’d rather be doing something than watching other people doing it.”

She's also an inveterate traveler and for 14 years owned a house in Austria. During one visit to Thailand she watched silk being spun, taking samples and having them made-up into dresses in Bangkok. These she wears with notable elegance to the opera and theater.

In fact, in her teens, Lucy considered a career in opera. But a chance reading all of The Magnificent Obsession by Lloyd Douglas put her firmly on the path to a life in medicine. It's the story of a feckless playboy who indirectly caused the death of a famous neurosurgeon, and which led him to embark upon a career as a physician. ‘The powerful effect of this book fired my decision to select a career in medicine,’ says Lucy.

The daughter of Armenian immigrants, she was born in St. Paul Minnesota. When she went to kindergarten she could not speak English. She entered the University of Minnesota in 1947 and left 10 years later, having earned a BA and an MA in psychology a BSc in medicine and her doctorate in 1957.

Lucy had several mentors in medicine and psychology and during the first two years of medical school she did psychological testing at a local private psychiatric hospital. Between 8 AM and 5 PM she attended medical lectures; at 5 PM she drove to the psychiatric hospital for consults until 10 PM; then home by 11 PM to study until 2 AM and then up in the morning at 6. Thus was formulated not only a strong work ethic, but an early bird ethos that even today sees her starting work at or before dawn. No wonder one of her friends calls her the Energizer Bunny.

There were five women in her medical school class of 110, but she says that being a woman was never a hindrance to her career. In fact, she notes in her memoir that at Philadelphia General Hospital, “I was asked to participate in endeavors beyond the confines of the hospital. This resulted in my involvement in many fascinating projects  that greatly broadened my world. Eventually, I became known as ‘the girl who couldn't say no.’ “In matters limited to science,” she adds coquettishly.

She entered with the goal of becoming a psychiatrist but during her clerkship rotations in psychiatry she decided that a career in that field would force her into close contact with too many colleagues who themselves appeared to her to be in need of psychiatric treatment. Her focus shifted to neurosurgery, with a residency in pathology which she describes as “the most remarkable time of my life.”

She went on to serve as chief of pediatric pathology and assistant neuropathologist at Philadelphia General Hospital, known as a place for the poor, the sick, the elderly and the insane; in other words, those people who private hospitals and usually turned away. While there, Lucy had an annual caseload of more than 1000 brains, plus surgical specimens including tumors nerves and muscles .With the advent of Medicare though, it became possible to farm out those patients to surrounding hospitals and Mayor Frank Rizzo ordered the hospital, where Lucy had served for 20 years, closed in 1977.

Because of her experience in pediatric neuropathology she began to work with pediatric child abuse cases, acquiring experience and expertise in that area, and in 1986 became president of the medical staff at Children's Hospital of Philadelphia. Since neuropathologists were in short supply the demands on their expertise involved so much traveling that she says, “I began to look upon the airport is my home.”

Lucy's association with the Medical Examiner of Philadelphia plunged her, she says, into the world of murder and mayhem. All unexplained deaths of infants and children became a special focus, including the unsolved murder in 1996 of Jon Benet Ramsey.

Of all her consuming passions––and the one that would be a high spot for any specialist in neuropathology -- she came into  possession at about this time of 46 slides of Albert Einstein's brain. The tissues were beautifully preserved and Lucy noted the absence of vascular lesions, the lack of gliosis and the pristine nature of the neurons. She held this precious trove for 35 years and then gifted it to the Mütter Museum where it is now on display, along with her bequests of the table and instruments belonging to Sir William Osler.

Dr. Rorke-Adams was married to Robert Rorke for 42 years. A sales manager with Plexiglas, he died at 89 in 2002. “He taught me how to laugh” she says with a grin at the reminiscence. Two years later she married Boyce Adams, an electrical engineer and, she says, “an inventor and a genius.”

A longtime fellow of the College, Dr. Rorke-Adams is also a trustee. She is the recipient of numerous awards, including one for excellence in teaching, and, she says, her greatest legacy is the Lucy Balian Rorke-Adams Chair in Pediatric Neuropathology at CHOP.

But even today, once every three weeks she's on call nights and weekends examining tissue and spinal fluid samples. In addition, she is a consultant to the medical examiner and gets cases from pathologists throughout the country and currently from Iceland and Sweden.

During her remarkable life in medicine, Lucy has found time to write some 300 articles in scientific journals, as well as an autobiography… and she is especially happy to have passed along her wealth of experience to hundreds, if not thousands, of medical students. She is sustained, she says, by her abiding faith as a Presbyterian … and finds it hard to understand how anyone can go through life without some religious belief.

Does she have any plans to retire? Hardly, she says, she's getting too much fun and satisfaction out of everything she does.