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Academic Medicine:
doi: 10.1097/01.ACM.0000351009.33868.ba
Medicine and the Arts

Commentary

Coulehan, Jack MD

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Dr. Coulehan is senior fellow, Center for Medical Humanities, Compassionate Care, and Bioethics, Department of Preventive Medicine, State University of New York at Stony Brook, Stony Brook, New York; (jcoulehan@notes.cc.sunysb.edu).

The old country doctor is an icon of American medical mythology. This man—sorry, no women need apply—is usually portrayed as dedicated, competent, compassionate, and bristling with wisdom. He could, in a single day, perform an appendectomy on a kitchen table, admonish an errant young man with venereal disease, and sit quietly at the bedside of a dying child. He embodied professional virtues we still identify with, in theory if not in practice. While the kindly, self-effacing country doc evokes a powerful image, was the real McCoy anything like the myth?

Arthur E. Hertzler, who graduated from Northwestern Medical School late in the 19th century and practiced for more than 50 years in and around the small town of Halstead, Kansas, provides us with a little insight. Hertzler, who also served as clinical professor of surgery at the University of Kansas Medical School during much of the early 20th century, published an autobiography called The Horse and Buggy Doctor in 1938. He must have struck a chord with the public because the book became a runaway bestseller, edging out Dale Carnegie's How to Win Friends and Influence People as the top nonfiction book of the year.

Dr. Hertzler scores himself highly on many of the attributes we would like to see in a doctor. Save for the “drunk with a headache,” he never refused to see a patient “no matter what the condition, or what the chances of remuneration” (p. 107). For him the patient's interest always came first. He believed that the doctor's primary obligation was to relieve suffering. “The important thing,” he wrote, “is that the suffering person wants action” (p. 52). Hertzler notes that “it is the relief of pain that chiefly interests the patient, and skill along that line is the big factor in the life of the man in general practice.” He viewed the physician–patient relationship as a tool to alleviate fear, anger, and depression, which he believed were barriers to healing. The horse-and-buggy doctor believed that the hours he spent at the patient's bedside engendered a “sense of security” for the patient and were therapeutic in themselves (p. 97).

However, his rampant paternalism is somewhat less to our liking. Hertzler was certain that experienced physicians always know best in medical matters; they should make therapeutic decisions for their patients. He saw no need for doctors to explain their reasoning or obtain informed consent. In fact, he argued that candor with patients was usually inappropriate because “the most disastrous results may follow a tactless warning” (p. 98).

Hertzler offers little comfort to those of us who favor teaching ethics and humanities in medical schools. He was stridently opposed to introducing such courses into the curriculum. In The Horse and Buggy Doctor, he disparaged such newfangled courses in sociology, ethics, literature, and the humanities because they “watered down” the medical curriculum and “detracted from the things worthwhile.” In fact, he wrote sarcastically that pretty soon medical schools would incorporate subjects such as “medical hemstitching or doily making” (p. 45). His attitude toward the arts in general was similarly dismissive, as we see in his disparaging remarks about Shakespearean tragedy.

Dr. Hertzler's dismissive attitude toward women is shocking. He wrote that female complaints are largely “due to maladjustment between the biologic and the ethical” (p. 138). In this spirit, he defined gynecologists as “unfortunate individual(s) whose mission in life is to aid the human female to correlate her biologic instincts with the dictates of Christian ethics” (p. 135). On the basis of his experience, Hertzler believed that symptoms like dysmennorhea, vomiting, and gastric distress arise from frustrated animal urges. However, he thought that women who expressed their animal urges risked even worse medical problems. All in all, he concluded, “unoccupied ladies are very likely to develop some sort of complaint” (p. 150). One wonders how the horse-and-buggy doctor would cope in today's world where women occupy themselves as physicians, lawyers, and corporate executives.

Hertzler's paternalism, misogyny, and antihumanities position are hard to stomach, even in light of his self-proclaimed compassion, benevolence, and dedication. Seventy years later, we reflect on our own professional lives against a backdrop of the myth that Doctor Hertzler helped create. The Horse and Buggy Doctor reminds us that medical professionalism is not a set of abstract virtues, values, and beliefs, but rather a tradition of stories, thousands and thousands of them, told and retold over the decades. Or centuries.

Jack Coulehan, MD

Dr. Coulehan is senior fellow, Center for Medical Humanities, Compassionate Care, and Bioethics, Department of Preventive Medicine, State University of New York at Stony Brook, Stony Brook, New York; (jcoulehan@notes.cc.sunysb.edu).

© 2009 Association of American Medical Colleges

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