Thompson, Ann E. MD
Dr. Thompson is professor of critical care medicine and pediatrics and associate dean for faculty affairs, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Editor’s Note: This is a commentary on Halperin EC. The pornographic anatomy book? The curious tale of The Anatomical Basis of Medical Practice. Acad Med. 2009;84:278–283.
Correspondence should be addressed to Dr. Thompson, University of Pittsburgh School of Medicine, M240 Scaife Hall, 3550 Terrace Dr., Pittsburgh, PA 15261; e-mail: (firstname.lastname@example.org).
In this commentary, the author asks, can educators learn from being reminded of moments of poor judgment or inappropriate behavior in the history of medical education, or should these incidents not be revived and revisited? The question is posed in relation to the accompanying article in this issue by Halperin, which examines the publication of a medical textbook that featured pin-up style photos of women but not men. Both in the past and now, attitudes and behaviors can be found within medical education that have helped to sustain cultural misunderstanding and bias. It may be difficult to become aware of these attitudes and the ways they can infect teaching, thus detracting from good care of patients. A more recent example from the author’s experience is discussed, regarding physician bias toward treating patients with HIV/AIDS. Readers are reminded that medicine not only exists in the context of social mores and customs, but helps create them. Examining the past can help to cultivate awareness of such inappropriate bias and generate strategies for resistance.
Those who cannot remember the past are condemned to repeat it.”1 As a woman who entered medical school with the last class with only 10% women, I do remember, not the textbook discussed in the article “The pornographic anatomy book?”2 in this issue of the journal, but slides thrown onto the screen during anatomy lectures and in classes that included similar images. There were jokes and descriptions of women patients that I remember to this day with discomfort and even hurt. So, do we need to be reminded of a bad time gone by, or should we heave a sigh of relief that it’s history and not bring it up again?
The article by Halperin helps us remember the past, and including two of the images from the text shows just how extraordinarily unacceptable the book was. By today’s standards the pictures are unthinkable. It is valuable to be reminded that what we now take for granted was once actually controversial and brushed off as coming from a bunch of “immature,” “kooky dames.”2 We can welcome Halperin’s essay as a prompt to be alert to equivalent issues in the present, whether they are already controversial or perhaps barely recognized.
Halperin states that a goal of the paper is to tell a story that teaches “us that medicine … occurs in the context of social mores and customs [and] that mutual respect between student and teacher … is an essential element of education.” He places the writing and publication of this particular textbook in the context of the women’s movement and makes it clear that the heightened awareness at that time of the unequal status of women in our society contributed to the book’s rapid demise.
Yet medicine not only exists in the context of social mores and customs, but helps create them. Physicians often share the biases of their times and culture, for better or worse, and impart those biases to their students, overtly or as part of a hidden curriculum. Had the book been published at a time when women did not feel strong enough to speak out, it would have quietly contributed to a culture that denigrated women. It is likely that students would have had slightly less regard for their female patients. It is not difficult to find examples of other attitudes or behaviors within medical education that have helped to sustain racism and cultural misunderstanding, as well as bias related to sexual preference, physical and mental disability, or other markers of diversity or difference. What is difficult is becoming aware of attitudes and teaching that detracts from good care for our patients.
For all the work he does in illuminating the inappropriateness of the tone and content of the book, though, Halperin barely touches another important failing of the textbook. Learning to examine a human body is a challenging task, especially for young adults who are commonly working on intimate relationships of their own. Not only must they learn what to look, listen, and feel for, they must learn to look closely at and touch portions of the body considered private. At the same time, they must learn how to be aware of their own feelings without acting on them. It is likely that the authors were genuinely anxious to make learning anatomy fun and relevant, and unlikely that they meant harm or offense. But the language quoted invites the student to see these models—and patients who might look like them—as objects of desire, and jokingly, but tellingly, indicates that the authors did. Putting aside the images and even concern for the students’ future patients, the language of the text raises questions about whether the authors fully respected the magnitude of the task confronting students or had altogether completed it themselves.
One additional point worth noting is one author’s response to criticism. While addressing a critic as “Miss, Mrs, or whoever you are,” he makes clear that he holds two doctoral degrees. He doesn’t entertain the possibility that she might also hold an advanced degree or, more importantly, that whether she does or not, her opinion as a person was just as important as his. When physicians are arrogant, they commonly lead the profession in directions we later regret.
More than 20 years after this book was published, I heard a physician speaking on a panel for entering first-year medical students express his rage over contracting HIV infection, presumably from a patient. His descriptors of the patient were as extreme as the figures in The Anatomical Basis of Medical Practice. Through the 1980s and 1990s our profession struggled with caring for HIV-infected patients, in part because of attitudes about the people unfortunate enough to have contracted it. It was necessary for the surgeon general of the United States to remind physicians that our tradition of care does not “abandon the sick … whoever they are and whatever they may have done to have ended up in such a fix.”3 How were the physician’s remarks received, and what imprint did they leave upon the students to whom they were directed? An examination like Halperin’s can help us to cultivate awareness of inappropriate bias and craft strategies for resistance.
There are probably very few today in medicine who can look at the images from The Anatomical Basis of Medical Practice and read the text quoted without recoiling. The question is whether we can be more mindful of similar issues in the present. Can we be attentive to the messages we send students and patients without the equivalent of a women’s movement? Can we become alert to attitudes and behaviors that we would not enjoy reading about in 20 to 30 years before a group draws them painfully to our attention? George Bernard Shaw said, “We learn from history that we learn nothing from history.” Let’s hope he was wrong.
1 Santayana G. The Life of Reason. New York, NY: Charles Scribner’s Sons; 1906.
2 Halperin EC. The pornographic anatomy book? The curious tale of The Anatomical Basis of Medical Practice. Acad Med. 2009;84:278–283.
3 Koop CE. Responding to the patient who has AIDS. Acad Med. 1989;64:113–115.