Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Monday, November 28, 2016
This is the third in a series begun nearly a decade ago concerning lies and truth told to patients and families by medical caregivers. This version of the third and final entry has been updated and lightly edited.
At the beginning, I had read three articles published in the medical literature that dealt with physicians' candor and "truth-telling." I was reminded of Pontius Pilate. In the Gospel of John, this Roman political leader was asked to decide whether Jesus should be executed. He believed Jesus had committed no capital crime. When he questioned Jesus about his actions, Jesus said that he was there to bear witness to the truth. Pilate famously responded, "What is truth?" and ultimately agreed to have him executed to placate the angry and powerful crowd. Christian tradition vilifies him because he chose to sacrifice one powerless innocent man for political reasons. But there is a little bit of Pontius Pilate in all of us, as these articles attest.
Lindsay Rockwell, DO, an oncology fellow, wrote a heartfelt essay (J Clin Oncol 2007;25:454-455) that laments the lack of "truth-telling" in oncology, particularly when it comes to the issue of death. She describes a young man with myelodysplastic syndrome and his father. The father complained to her that no one had told the family that the young man was dying, despite the short remissions and the inevitability of death. She is dismayed that death was not discussed and instead the discussions concerned additional therapy, none likely to succeed.
Her essay was followed by a commentary written by Timothy Moynihan and Linda Schapira. They express concern at the potential damage failing to communicate can do and that we often do not prepare our young physicians sufficiently in this art. But though they are in general agreement with the major points of the essay, they wonder whether the father was told but didn't hear the information, whether Rockwell was present for all discussions, or whether the father refused to give up and would not to face the reality of the impending death of his son. They even wonder, "Could it be that Rockwell is expressing her own grief as guilt for not speaking up when she saw the inevitable truth?"
What Is Truth?
Farr Curlin, MD, and colleagues conducted a random survey of physicians in all types of practice by mail and received 1,144 responses to questions devised to determine the physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for ethical or religious reasons (N Engl J Med 2007;356:593-600). Examples are abortion for failed contraception, giving terminal sedation to dying patients, and prescribing birth control to adolescents without parental consent. (The authors report that 52% of all respondents had ethical or religious objections to abortion for failed contraception.)
Most physicians responded that all doctors have an obligation to present all options (86%), that it is ethically permissible for doctors to explain to patients their moral objections (63%), but that they should then refer patients to another physician that has no objection to the requested procedure (71%). The authors then estimated the number of patients affected by the minority, if generalized to the entire population. They conclude that 40 million-100 million Americans have physicians who feel no obligation to present all options or who would not explain that they have moral or religious objections to the procedure and feel no obligation to refer them to a more agreeable physician.
Without questioning the sincerity and conviction of the respondents, we may ask who is more truthful, a physician who believes on ethical grounds that abortion for failed contraception is always wrong and doing anything to abet the procedure is also wrong, or the physician who believes abortion is wrong, but also holds that he cannot impose his views on patients so helps them find a willing physician? One could argue that the first is more truthful to his convictions and the second more truthful with the patient. One could also argue that the physician's first obligation is to the patient's well-being, so he must help the patient obtain the procedure she desires, even though he thinks it wrong. The counterargument is that if he believes abortion in this case is murder, that he has no choice but to avoid abetting the patient.
Telling the Truth
The third article by David Studdert, LLB, ScD, MPH, and colleagues takes an economic look at telling the truth (Health Aff J 2007;26:215-226). They asked whether full disclosure of adverse outcomes actually reduces the providers' liability exposure, as some believe. They tested this theory by modeling the litigation consequences of disclosure. They compiled data on the historical frequency of litigation when the patient suffers a severe medical injury, both when due to negligence and when not. To obtain an estimate of the net impact of litigation, the authors polled 78 experts in patient safety, risk management, malpractice liability insurance, and plaintiff litigation, including lawyers on both sides. They defined serious injury as that which leaves the patient with a permanent disability or with a temporary disability that is very severe while it lasts.
They concluded from their study that, among patients whose severe injury was due to negligence, full disclosure would deter 32 percent of patients from suing and would prompt claims by 31 percent of those who would not otherwise have sued. Among patients whose injury was not due to negligence, disclosure would deter 57 percent of those who would have sued and prompt 17 percent of those who would not have sued. Overall, the experts predicted there was a 5 percent chance that the volume of claims would decline or remain the same and a 95 percent chance they would increase; the predicted outcome of compensation cost was the same, a 6 percent chance of declining and a 94 percent chance of increasing.
The authors make a key point: about 80 percent of all serious injuries due to negligence never trigger litigation. Thus, there is a huge reservoir of unlitigated injuries meaning that a small shift in that group could have much greater financial repercussions for doctors, hospitals, and insurers than the deterrence from suing of an equal percentage of patients. Though the authors predict that full disclosure would cause an expansion of litigation and monetary consequences of potentially great magnitude, they do not say, "don't tell the patient if not forced to."
The main audience of the report is policy makers, cautioning them to consider the consequences of full disclosure policies. They point out the broad consensus that disclosure of unanticipated outcomes is desirable because, as in other industries such as aviation, openness about error is critical to development of effective prevention. They continue, "there are also compelling ethical reasons for telling patients the truth about all aspects of their care."
So what will policy makers in government, the private health industry, and medical practices do? A cynic will say they will continue to follow traditional risk management procedures, which does not include full disclosure, to contain litigation costs and overall health costs. The optimist will say they will do the right thing, full disclosure, so errors may be addressed and corrected and improve the quality of care.
So, What Is Truth?
I am confident that every reader has opinions about each of these circumstances and I am equally confident that the most of those opinions are strongly held. But as is true for discussions of politics and religion, such case studies as those presented above often don't allow room for subtleties on any side for fear of taking a step onto a slippery slope that endangers one's bedrock principle. One may hold a bedrock principle, but the specific circumstances tend to be messy and influenced by the many complexities of day-to-day living and by our own internal conflicts.
We each have a moral/ethical compass formed by our parents, culture, education, and religious faith, or lack of it. However, these positions are not immutable; they can be modified by preachers, scientists, literature, travel, and other external influences, as well as by experience and the greater wisdom (we hope) that comes with age. But we still make "right" and "wrong" decisions.
So, what is truth? I don't have the answer, but I have an answer for myself. Truth in dealing with patients is based on transparency with humanity and charity that attempts to ease their burden. And for life in general, I believe my professor of moral theology had it right: for each individual, a considerate, thoughtful, and well-informed conscience that takes all potential consequences seriously must be the final arbiter of right and wrong. My conscience always lets me know, at times reminding me even decades later, when I have already acted against it.
Thursday, November 10, 2016
Six years ago, I wrote a column titled, "Five Great Lies of Medicine." I wrote an updated and expanded version of that column, which published last month (Oncology Times, 10/10/16 issue).
It included the infamous statements by some surgical oncologists to the patient or family that "We got it all." That and four other "lies" expressed a need to be more specifically honest with the patient and the family; for example, "We got all we could see and detect. But we know that microscopic parts of the cancer often remain and threaten to grow and reemerge. So additional therapy may be necessary." Or something like that.
Several years ago, I also wrote a column, "Three Great Truths of Medicine," because there are also "truths" in medicine we rarely talk about. By that, I mean common knowledge among medical professionals that is often not recognized or clearly understood by the public. We may not wish to focus on these truths because of fear that patients may lose confidence in us and in our ability to provide excellent care—and certainly, when and if such a discussion of these generic, almost philosophical, issues may not be appropriate when one is in the process of laying out the options to a patient, when confidence in your abilities is a key factor in the patient's sense of being in good hands. But recognizing these truths with humility is good for both the caregiver and the recipient of care. Here are a few.
There is no reliable, public mechanism for choosing a skillful doctor.
It is not easy for the average person to choose a personal physician based on his or her professional skills, experience, or results. Virtually any MD can obtain and maintain a license to practice medicine. Medical licenses are very rarely revoked, and then only for committing a felony, writing excessive drug prescriptions, or defrauding Medicare.
There is no formal and ongoing assessment of the quality of care provided. In most states, doctors are required to obtain a number of continuing medical education credits, a means of trying to force them to update their education. But these are often based on attendance at medical meetings and taking online courses on topics such as the laws for prescribing narcotics, sexual harassment in the workplace, or reviews of some aspect of medicine. Certificates on his office wall from prestigious medical schools, hospitals, or training programs are not very meaningful in assessing the quality of his care.
So how does a patient choose a doctor? Often it is based on:
- advice from a friend or family member;
- referral to a subspecialist by one's primary care doctor;
- reading an article in the press; or
- choosing someone at a convenient neighborhood hospital.
One may also go online to consult doctor evaluations for a fee, which are often based on some unknown number of patient satisfaction surveys. The latter are a pet peeve of mine; very early in my career I learned that patient satisfaction was an unreliable measure of the quality of medical care. Some of the worst doctors (quacks) I worked with as a resident were adored by their patients.
Even when a relative or friend asks me where I would go for care of a medical problem, I often base my recommendation on generic information about an institution or a doctor I have come to know and trust; this may be a bit better than the other reasons, but it still doesn't get to the core issue because I have no data on the quality of that physician's care, only a sense of it from experience or anecdotal evidence. Some of the standards in place today deal mostly with process measures, which are useful. But if I am likely to have a major operation by a surgical oncologist, I don't care about his processes very much, but I do care about his results. We need national, objective, transparent measures by which we can get a notion, at least, of the quality of care provided by physicians and hospitals.
Doctors and other caregivers make mistakes.
This is obvious since doctors are human. But it is possible to reduce errors considerably. The commercial airlines are the model for dealing with pilot error. There is oversight by federal and local agencies, recurring tests of performance in flight simulators, medical exams to assess the continued ability of the pilot to perform from a physical and psychological point of view, and a careful review of his flight performance looking for early signs of poor judgment or performance. And there is an age limit for piloting a commercial airplane.
An easier and often overlooked approach to reducing medical mistakes is that many of them are not due to incompetence, but to a faulty system of care. It has been shown repeatedly that errors are reduced significantly by process measures such as the routine use of checklists, patient ID bracelets, and practice standards where appropriate (e.g., the use of an agreed upon regimens of antibiotics or chemotherapy for specific conditions). Some doctors balk at the use of guidelines or protocols as "cookbook medicine." But standard approaches to standard situations reduce the likelihood of error, antibiotic-resistant bacteria, and dosage errors. It also has the side benefit of being able to learn about the effectiveness or side effects of a particular regimen instead of having numerous, one-off variations.
The quality of a physician's care is often inversely proportional to the elapsed time since completing his or her training.
This is sad but true. Studies have shown that the quality of care stays relatively steady for 10 years or so after training, but often slowly declines thereafter. Often as one ages, study of the current medical literature gradually declines to only reviewing the abstracts, then reviewing only the table of contents, and then just putting the journal on top of the pile of unread journals, never to be opened. The same is true of medical meetings, with a gradual decline in the frequency of attendance and, even when present, hearing fewer and fewer presentations. There are many exceptions, of course, but on average this trend holds. (I must fess up that, to some degree, this describes my trend as well. I still read specific abstracts and occasionally entire articles, but much less than I used to. My excuse: I stopped caring for patients 20 years ago because I took on an administrative position that left insufficient time to be available to my patients.)
Declining study of journals and engagement in medical meetings can lead to excessive dependence on one's own anecdotal experience. Medicine changes rapidly and keeping up is not easy. Once a physician is confident and feels he/she is doing a good job, the urge to learn more may decline. This is human nature in action.
What often prevents catastrophe is the salvation provided by good judgment. Over time many, if not most, doctors develop increasingly good medical judgment about when and when not to operate, radiate, or treat at all; and they learn from their earlier mistakes or from colleagues. To some degree, good judgment can make up for being a bit less up to date, and it certainly can convince a doctor that she doesn't know enough about the problem, and then using good judgment by referring the patient to another doctor or at least discussing the issue with an expert.
A doctor working with partners or colleagues has a potential advantage when striving to provide excellent care.
I cannot count the times I was given very good advice from a colleague when I had a problem or difficult decision to make in a patient's care. Reviewing a bone marrow sample at the two-headed microscope with a superb lab tech saved my butt a number of times. However, there is a big "but." The colleague must be willing to disagree with the physician's opinion, which may cause hard feelings. The doctor asking for help must take the advice seriously and, if necessary, get another opinion from a different colleague. Some of these issues are resolved at a regular tumor board meeting, which often raises novel approaches or a change in the sequence of care.
Being a physician is a privilege and an honor.
We have a special place of honor in society that is awarded to us and we must not let our egos or the pursuit of financial gain tarnish our commitment to serve our patients. The patient comes first and, when we forget that for any reason, we rightly lose the trust of patients and no longer deserve our special status in society.
Monday, October 10, 2016
Several years ago, I wrote a column titled, Five Great Lies of Medicine (Oncology Times, 1/25/08 issue). It was well-received with responses mainly from laypeople. Recently, a reader of Oncology Times asked me if I planned to write an expanded version. I liked the idea and the result follows. Since the original is almost 10 years old, readers at that time are unlikely to remember it. So I started this column with the old one, I made some edits in it and then added a few more "great lies." The last several are lies of omission, usually the failure to provide necessary information or a service that can be of profound importance to the patient and should be addressed.
I was in my late thirties or early forties before I was willing to call them "lies." I think I had to reach a certain threshold of maturity, experience, and open-mindedness to accept the lies as such. These are not "white lies," largely innocent with no damage done to another person (damage to the liar is another matter). Some of these are frank lies, others are half-truths, and still others are statements meant to mislead or convince the patient that only he/she is responsible for a decision. The statements listed are not always lies, but too often they are. When there is a major unspoken reservation after one of these statements, it is my belief that it becomes a lie. Here are some relatively common lies in medicine.
We got it all.
This is the king of all lies in cancer. It is not uncommon today for a cancer surgeon to tell a patient or family member triumphantly, "We got it all." Although it is justified in some instances, for most carcinomas this is blatantly wrong and biologically impossible since many are systemic in nature and micro metastases remain in the patient even with "clear surgical margins." It misleads the patient and family into thinking the patient is cured. Surgeons who tell this lie defend themselves by saying, "What I meant was that we got all of the tumor we could see at surgery," or "Of course, the patient will need chemotherapy for the remaining microscopic cancer." So why didn't he say that? I hear various explanations: "No need to burden the family and patient at this time," or, "You never know; I might have gotten it all. I had a patient once that…" This introduces the second great lie.
You never know.
When I made rounds with fellows and junior faculty and we were faced with a difficult diagnostic or therapeutic decision, I would ask each to give his or her opinion and to explain the choice. One junior faculty member back in the 1970s often chose what seemed to be an excess of additional diagnostic tests or images, and he often chose therapeutic options that had a next to zero chance of success. When his choice was challenged he would say, "You never know," meaning this might be the one in a million in which there is a useful or positive result.
It drove me nuts. I wanted to grab his lapels and shake him saying, "Of course we can't be 100 percent positive about any action we take; this is biology and medicine about which we are woefully ignorant, but we must apply what we know to make the best reasoned choice we can. You are using sloppy logic and, even worse, you are lying to yourself and possibly to the patient as well." Fortunately, I never did show any emotion or grab his lapels. Unfortunately, this lie is still used today, if not in so many words, or even with no words at all.
The cancer patient with the third or fourth recurrence is offered an ineffective therapy because, "You never know," and the lie is compounded when there is a substantial financial incentive to give the therapy. A related "big lie" follows.
I did it because the family insisted on more therapy.
This is a common excuse for giving or doing something that is almost certainly not in the patient's short- or long-term best interests. It is often excused by confusing "patient choice" and sound medical advice. Patients and/or families should be participants in decisions so they may express the boundaries of action they are most comfortable with. But the doctor is duty bound to do the same. To blame the family for highly questionable interventions is an abrogation of responsibility by the doctor. It is very hard to say "no" to a desperate patient or family. Nobody said this would be easy.
It's your decision.
This is a variant of the preceding lie. There is no question doctors influence patients' decisions. Doctors have biases that may be based on scientific data or a common standard of practice, and it may therefore be reasonable to make a strong recommendation. But in some cases the bias is personal, such as wanting to get more patients on a clinical trial, to do more surgery, to increase revenues, or to avoid having to deal with a difficult patient. In these cases, how the choice is presented along with the enthusiasm and salesmanship of the doctor can make it far more unlikely the patient will choose an alternative option, even when at the end of the explanation the doctor says, "It's your decision."
In a technical sense, it is indeed the patient's decision to go forward, but the strong conviction of the doctor has severely reduced the patient's degrees of freedom. As noted above, a strong recommendation is sometimes indicated, but when those instances are based on a personal preference, one must be extra careful to balance any bias by providing clearly understood information and transparency.
He's a "good doctor."
Patients require referrals to specialists and most often depend on their current physician to recommend one. Physicians usually refer to specialists they know personally or know to be competent by experience or word of mouth. But they may refer a patient because the specialist is a golfing buddy, works in the same building, or is a business partner. The specialist may be quite competent, but one must ask oneself the simple question: If the patients were members of my family, would I send them to this specialist? Or when one tells the patient, "She is a good doctor," does he really mean, "She is a good enough doctor," or "She can probably handle this case because it isn't so complicated?" Referral relationships are fragile and may be influenced by non-medical issues. One must be diligent to avoid exposing patients to unnecessary risks in order to satisfy a social or business obligation.
Failure to explain the relative costs of diagnostics and therapy.
I don't know many physicians who enjoy discussing the costs that must be borne by the patient and his family. Most avoid the topic unless asked. But in today's world, it is not uncommon for the patient and family to carry a huge burden of debt they cannot possibly manage with their income. I am not suggesting one offer a cheaper regimen that is inferior therapeutically. It is the physician's responsibility to describe the choices along with their relative costs. If the best therapeutic regimen is clearly superior for curing or has the likelihood of a prolonged period of a high quality of life, the choice is clear, but the costs should be explained to the patient and family so they can begin asking about payment options and dealing with insurance agents.
Failure to describe the usual post-therapy quality of life of similar patients.
The short- and long-term handicaps that may occur in the ensuing months or years of therapy is a lie of omission. Edema in the arm after a mastectomy is common enough that helping the patient prepare for such an event would be prudent. Failure to prepare the post-prostatectomy patient for a leaky bladder or impairment of erection is another lie of omission. In the early days of bone marrow transplantation, the long inpatient stays and the ravages of graft-versus-host disease were new and puzzling problems, with the dangers of immunosuppression thrown in. As time passed, transplant doctors did a much better job of explaining these problems to families and patients, including their therapeutic options.
The unavailability problem.
As a retired physician, I am often asked at civic groups or by acquaintances, family members, and other casual friends about not being able to contact their doctor, or the nurse or knowledgeable clerk. The doctor is too busy or traveling or in the OR. This often leaves the patient with no way to ask a question or get even minimal information. I am sympathetic with the doctor's busy day with a waiting room full of more patients. And, at times, patients can expect too much attention. But at least there should be a window of time when the doctor or staff person would be accessible to triage the seriousness of the issue.
Thus, while each of the above statements or actions can be used honestly and justly, they are too often used for more negative and sometimes shameful reasons and biases. The test is the motivation found when being honest with oneself and, at the very least, facing the fact when one is not.
Wednesday, August 24, 2016
Some years ago, I splurged and bought "Essential Art House—50 years of Janus Films." This anniversary collection of DVDs contains 50 films released in the U.S. by Janus, which was the major source of foreign and art films in the 1950s and 60s.
Watching the films has reminded me of many visits to small, off-beat movie theaters with sticky floors and one guy who sold and collected tickets, made the popcorn, and probably ran the film. But most of all, I was reminded of experiencing the pleasure, wonder, and mystery of these decidedly non-Hollywood movies (even though some were made in the U.S.). Though I didn't always grasp nuances, the films made me think and often left a lasting impression.
The foreign films with the greatest lasting impact on me were mostly made by Ingmar Bergman.
Because I am a physician, I believe, his single most memorable and thought-provoking film is Wild Strawberries. It was released in Europe in 1957 and had its premiere in the U.S. in 1959 at the Beekman Theatre in New York City. When I watched it at home, it had the same impact as when I first saw it, the difference being that I grasped its themes much more fully, probably because the protagonist is a physician celebrating 50 years in medicine and I was very close to that mark.
One Physician's Journey
The story begins as Dr. Isak Borg, an esteemed professor emeritus of medicine, is preparing to drive from Stockholm to Lund to be honored for his 50-year career. His first words foretell a basic theme, "Our social relationships are limited, most of the time, to gossip and criticizing people's behavior. This observation slowly pushed me to isolate myself from the so-called social life. My days pass by in solitude." His daughter-in-law accompanies him on the drive. He has had an unhappy family life both as a child and as an adult. His wife left him for another man, largely because of his unsympathetic and cold demeanor. And it is clear that his son, who also is treated coolly by his father, is imbued with the same sadness and loneliness.
Throughout the movie, he has dreams of his life. In his first dream, he is lost in a sterile looking city with a large clock having no hands. A horse-drawn hearse without a driver rapidly approaches and when a wheel of the carriage hits a post, the casket falls to the street and pops open. He looks in, and it is him lying in the casket. As the movie progresses, one thinks it is as much about the death of his soul rather than the body that the dream shows him.
As the journey progresses, he and his daughter converse. She eventually tells him, "You are a selfish old man. You don't care about anything, and you never hear anyone but yourself. All this is so well hidden behind your benevolent, kind mask. But you are as hard as stone, even though everybody says you are a great humanitarian person. But the ones close to you know how you really are."
She then reminds him of what he said (and had forgotten) when she asked to spend a few weeks at his house; there was a problem in her marriage (she was pregnant and wanted the child, her husband did not) and she wanted time to think. She reminds him that he said, "Don't try to bring me into your conjugal problems, because I don't care at all. Everyone has his things to think about. I don't have any respect for the pain of the soul; so don't come here to cry. But if you need spiritual support, I can tell you the name of a priest or analyst."
No wonder his wife left him and his son is estranged. But it isn't that simple. As the movie progresses, instead of being repelled by him we gradually begin to feel sympathetic as the doctor slowly faces his past honestly. This is made possible by the magic of the movie and especially by the remarkable acting of Viktor Sjostrom, who plays the doctor. He (and the doctor) were 78 years old at the time.
During the journey his second dream is of a happy time in his youth picking wild strawberries with his first love, Sara. But she ended up marrying his best friend and he never got over that loss. In a heartbreaking scene, the young Sara, as he remembered her, tells him, as the old man, that she will not marry him. Finally, she tells him to look in the mirror. He refuses at first then looks and says, "It hurts me so." And she replies, "You should know why it hurts so much. But you don't, in spite of your science, you don't know anything indeed."
Immediately following his meeting with Sara in the dream, he walks into a classroom like the one he taught in. This is the scene that led me to write this essay. In the scene, Dr. Borg is the student, not the professor, but he is still 78 years old. The professor is giving him a test. He is asked to identify something under the microscope, but he can't see anything. He is then asked to interpret something written on the blackboard, but he does not comprehend the writing. He then is asked to diagnose a woman lying on a bed. He looks at her and says she is dead. The woman promptly gets up and laughs loudly at him. The professor writes down his conclusion, "You are incompetent."
Importance of Humility
But I left out one detail, which has occupied my thoughts more than any other aspect of the film. When he was asked to read what was on the blackboard and couldn't, he was told it said, "The first duty of a doctor is to ask for forgiveness." That hit me right between the eyes the first time I saw it over 50 years ago and the last time I saw it more recently. Strangely, despite many detailed critical analyses of the film over the years, I could find none that considered what it meant.
The statement can be interpreted in many ways; here is my understanding of it. I believe the movie, at its heart, exposes in Dr. Borg (and in us, if we care to look) a devastating lack of humility, even as he is honored and esteemed in his profession by colleagues and the public.
The soul of practicing medicine is a solemn social contract under which patients surrender themselves to us and trust us to do what is best for them. Because of patients' vulnerability and trust, we doctors have a great deal to ask forgiveness for, our relative ignorance, the times we act without charity, and the invasion of patients' bodies with knife or rays or chemical. A doctor without a substantial and persistent sense of humility every day is a poor doctor.
Unlike many of Bergman's movies, which are often unrelentingly dark, toward the end of Wild Strawberries Dr. Borg begins to see and accept his shortcomings and move toward deeper insight and reconciliation—the first steps toward humility and redemption.
Tuesday, August 9, 2016
I have written over the years about doctors and nurses, writers and poets, as well as other groups. But I am a physician first.
I have met, worked with, observed, and read about hundreds of physicians in the 50-plus years since I entered medical school. There are many that I have respected, usually for their medical skills, intellect, or efficiency.
Some I have deeply admired, often for their humanity, their view of medicine as a calling and a sacred trust, or for the personal sacrifices they made for their patients and profession. And a handful have stimulated not only respect and admiration, but also a sense of awe and wonder. I would like to tell you about one of the latter, an American physician of my grandparents' generation that I never met, but have read about extensively.
William Carlos Williams was a general practitioner and pediatrician in New Jersey. He cared for a working class, mostly poor, immigrant population early in the 1900s through the Great Depression of the 1930s when house calls were a regular part of each day, and thereafter until his death in 1963. Why he is special, and the only reason I know of him, is that he was also a poet, probably the greatest successor to Walt Whitman as a uniquely American poet. He wrote about ordinary people and everyday things in his community and his practice.
Williams was drawn to the arts at a young age and spent his life as a fulltime physician while trying to be a full-time poet. So he wrote in his carriage on house calls, between patients and after office hours, "stealing" time from his practice and often complaining of overwork and the lack of time for writing. However, despite the urgings of his colleagues in the arts, he refused to give up his practice to write and refused lucrative Manhattan practices.
Listen to Williams talk, first about "The Practice" from his autobiography: "It is the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life. I have never had a money practice; it would have been impossible for me.
"But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness that was affecting them, it was as though I were re-awakening from a sleep. For the moment I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself, as from any other sleep, rested."
And more about his patients and society: "I don't care a rap about what people are or believe. They come to me. I care for them and either they become my friends or they don't. That is their business. My business, aside from the mere physical diagnosis, is to make a different sort of diagnosis concerning them as individuals, quite apart from anything for which they seek my advice. That fascinates me.
"From the very beginning that fascinated me even more than I myself knew. For no matter where I might find myself, every sort of individual that is possible to imagine in some phase of his development, from the highest to the lowest, at some time exhibited himself to me. I am sure I have seen them all. And all have contributed to my pie. Let the successful carry of their blue ribbons; I have known the unsuccessful, far better persons than their lucky brothers."
And finally, he speaks about his poetry, for which he began to be recognized by literary critics only late in life: "…I have never felt that medicine interfered with me but rather that it was my very food and drink, the very thing which made it possible for me to write. Was I not interested in man? There the thing was, right in front of me. I could touch it, smell it. It was myself, naked just as it was, without a lie telling itself to me in its own terms."
As with medicine, poetry was not a pastime for him, which was made clear in his ever-present red notebook:
If I did not have
I would have died
So we hear a man deeply committed to his profession, his patients, his community, and his poetry. The four are fused, inseparable and interdependent, nourishing and revealing secrets to one another, about his patients and about himself.
Williams wrote many poems, his magnum opus being the book length "Paterson," in which he writes about the city, the times, and especially the people in all their glory and decadence, disease and health, joy and sorrow. His style of writing is not ornate, but direct and tangible, though not necessarily simple or straightforward. In "A Sort of Song" he describes his style, using a metaphorical snake and flower; the phrase in the second stanza (my brackets) is his famous statement on poetry:
Let the snake wait under
and the writing
be of words, slow and quick, sharp
to strike, quiet to wait,
—through metaphor to reconcile
the people and the stones.
Compose. [No ideas
but in things] Invent!
Saxifrage is my flower that splits
He also wrote The Doctor Stories and poems about his practice and patients, some of which were compiled and introduced by Robert Coles, himself a famous physician and author.
As Coles says of them, "…the sheer daring of the literary effort soon enough comes to mind—the nerve he had to say what he says. These…accounts meant to register disappointment, frustration, confusion…or, of course, enchantment, excitement, pleasure…These are stories that tell of mistakes, of errors in judgment; and as well, of
one modest breakthrough, then another—not in research efforts of major clinical projects, but in that most important of all situations, the would-be healer face-to-face with the sufferer who half desires, half dreads the stranger's medical help."
Needless to say, The Doctor Stories, which I have read several times over the years (and that I highly recommend), were the final steps in elevating Williams to the upper level of my pantheon of doctors. He was by no means a saint and often a curmudgeon, but he worked hard every day at his passions, medicine, and poetry. In both his practice and in his art he respected his poor, societally insignificant patients enough not only to care for them, but to listen to them, to study them, to understand them and to write about them in all their humanity.
I am awestruck by his perseverance, sensitivity, artistic talent, and his commitment to the medical profession, which for him was clearly a calling and a sacred trust, as well as the lifeblood of his art. Though he died over 50 years ago, in his stories and poems he still has much to teach us about being a doctor, and about life.