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The Woman in the Mirror

Humanities in Medicine

Huyler, Frank MD, MPH

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doi: 10.1097/ACM.0b013e3182959e16
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Not long ago, in the middle of the night, I took care of a woman with a large anterior myocardial infarction. She was homeless, filthy, morbidly obese, and schizophrenic. She was also drunk, writhing and gasping on the gurney.

“Sorry,” the paramedic said, shaking his head “We picked her up at a convenience store. She said something about chest pain. We couldn’t get a line. She won’t tell us her name. But we got an EKG.”

He handed it to me. The pattern was unmistakable.

“Are you having chest pain, Ma’am?” I asked. She ignored me completely, and instead, she began screaming at the nurses who were trying to start an IV and attach her to the monitor.

Leave me alone you bitches leave me alone leave me alone get away from me you stupid bitch— After a while it began to sound like a chant, the refrain repeated again and again.

So we went through her purse, looking for her name. And there it was on, among other crumpled papers, an unfilled prescription for Plavix.

In the meantime we activated the cath lab. As we waited, and gave her morphine and nitroglycerin and heparin and all the rest, I pulled her records up on the computer. She had been discharged only a few weeks before with a stent in her left anterior descending coronary artery.

Instantly the story became clear: She had not been taking her Plavix and had clotted off her stent.

The morphine finally calmed her, and she went quiet for a moment.

“Why weren’t you taking your Plavix, Ma’am?” I asked.

“I didn’t have no money!” she yelled.

The note described the efforts of the social worker to get her prescription filled by the hospital pharmacy. She had been discharged with a month’s supply and had only to show up at the pharmacy when that supply ran out.

“The medicine was free,” I said.

“I meant for the bus!”

After weeks in the hospital and after many hundreds of thousands of dollars were spent, she survived. Then she was discharged back to the street.

Doctors are often suspicious of including the humanities in medical education. The resistance can be summed up succinctly: What’s the point? When there is so much to learn, why spend precious time in medical school or residency considering the impractical, the subjective, the indeterminate, and the artful? If we’re going to ask questions, we might as well pick ones that have practical use and are possible to answer.

This is an understandable and, I must confess, often appealing view. Yet how many of the problems that clinicians face in daily practice are scientific, in any meaningful sense of the term? On a larger scale, how much does science even influence our health care system? It is a system that reflects primal cultural traits as much as anything else: thirst for youth and health, fear of illness and death, greed in all its forms, conflicting notions of both collective and personal responsibility, and socioeconomic hierarchies above all.

My patient never became a case study in a small-group discussion for medical students, but she easily could have. Where to start? It’s hard to know. Do we start with examining how society views and treats the mentally ill? Do we start with questioning the wisdom of the cardiologist who put a stent into a schizophrenic, alcoholic street person, knowing that compliance with an outrageously overpriced medication would then be vitally important? If the cardiologist had not put in the stent, would we fault him or her for failing to provide the standard of care? Why do we spend $7,000 on a stent, when we do not consider providing the patient with housing or food? Why does a stent cost $7,000, anyway?

Everyone’s eyes may glaze over, but she is on the gurney nonetheless, cursing and gasping and trying to pull out her IV.

By their nature these are questions without objective answers, and the temptation to throw one’s hands up and go back to PowerPoint presentations on stent reocclusion and the role of platelets in thrombogenesis is strong. It’s also a temptation that medical culture has largely been unable to resist: As a rule, we absolve ourselves from participating in debates that resist empirical solutions, that require argument and persuasion—just as we tend to shy away from issues that ask for, and at times require, emotional engagement.

Yet the questions remain, and we do in fact answer them. Often the answers are absurd and escape formal scrutiny: We will provide you with a stent and Plavix but not food and housing; we will provide you with an antipsychotic medication but not a mental institution; we will activate the cath lab in the middle of the night for you, call a highly trained group of doctors and nurses in from home, spend hundreds of thousands of dollars on an ICU stay, and send the bill for all of it to the taxpayers. But a bus pass might be tough, and besides, if you can afford vodka, you can afford bus fare, mental illness or no mental illness.

Put another way, answers to subjective questions have consequences that are just as profound, and just as tangible, as answers to objective ones.

So what is the point of studying the humanities in medicine, and why is doing so worth at least some of our time?

One answer is that the humanities, like science, are a tool. The humanities, broadly and imperfectly defined as they may be, nonetheless concede what the sciences resist—that we are irrational creatures much, if not all, of the time. Our collective values and beliefs may be eroded by evidence, but they are rarely overturned by it.

Pure empiricism, in other words, gets us only so far, in part because it so dramatically limits both the scope and the relevance of the questions we can ask. Empiricism lacks the ability to generate emotional power, and crowds are like children: Logic hardly sways them. Like it or not, in an era of Twitter and Google and bottomless seas of information, in an era of news that is always breaking and of endless dueling facts, the ability to distinguish truth from falsehood, to discern narrow agendas from collective ones, has never been harder.

But the humanities have the power to move us. At their best, they can approach the resonance of personal experience. They have the ability to illuminate stakes and choices alike, to make numbers come alive, to help distinguish both the reasonable from the absurd and the decent from the indecent. The humanities have the power to invoke moral authority, to invoke feelings of outrage as well as feelings of compassion, to inspire us to be better, and to caution us against being worse.

Perhaps studying the humanities can also help us empathize with our patients. Advocates of the humanities in medicine often make this argument, and it may even be true, but I think it misses much of the point.

Being a physician is about more than empathy—It is as much about doing your job when you feel no empathy whatsoever. My patient was foul-mouthed, abusive, uncooperative, and unlikeable in virtually every way. But we weren’t there to empathize with her—We were there to save her if we could.

In other words, studying the humanities in medicine is not about indulging in sentimentality, in earnest appeals for empathy that is often impossible to achieve. It’s not about making doctors nicer, although few will complain if that happens.

Instead, studying the humanities in medicine is about helping doctors and medical students become more aware, more insightful, more reflective, and—ultimately—more influential in shaping the trajectory of health care. It’s about encouraging the facility, willingness, and ability to enter into the larger public debate in these cacophonous times, when collective silence will not serve the medical profession well. And, finally, it is about providing an outlet for both emotional engagement and self-reflection in a culture that typically denies both, looks outward rather than inward, and too often ignores not only the personal costs but also the personal rewards of medical work.

I am midway through my career, and I can hardly remember any of the thousands of lectures I’ve attended, and fewer still of the tens of thousands of pages in medical textbooks and journals that I’ve read. I can usually produce the answer when the whistle blows, but at this point my formal medical knowledge has become truly Pavlovian, automatic more than conscious, akin to speaking a once strange and foreign language. Perfect fluency will always escape me, but I can usually get to the train station. This process, of course, was and remains necessary. Yet I do not think I’m alone in saying that it also seems incomplete, and only partly applies to clinical work as I know it.

What I do remember are the patients I’ve seen over the years; the many moments, dramatic and small alike; the many colleagues and residents and students and nurses I’ve worked with; the off-color jokes and the dark humor; the consultants I’ve liked and those I haven’t; the pleasure of coming home to clean sheets after a night shift; the flash of dread when the trauma pagers go off; the black, excoriating feeling of making a big mistake; the distinct aesthetic satisfaction of suturing a laceration; the intense stillness when a code is called and everyone stops; the occasional, silent glory of being right; the grief of the consultation room and the relief of the consultation room; the sounds and lights; the radio, the sirens; the screaming drunks and the quiet drunks; the brave and the cowardly; the manipulative and the honest; the intelligent and the idiotic; the stoic and the histrionic; the innocent and the guilty; and all the many in between. Somewhere in the impossible mix is the sense that all of us in medicine are doing work, however imperfectly and at times despite ourselves, that counts. It is precisely this sense of significance, of stakes that actually matter, of work with larger meaning, that drives the rigor and discipline of medical culture, the physical exhaustion, the endless phone calls in the middle of the night, all those pages both read and written, and all those lectures both given and received.

A few weeks ago, stopped at a red light, I saw a large homeless woman pushing a shopping cart full of trash down the sidewalk. The sun was bright. She wore a straw hat, dark glasses, and a green plastic poncho. She was muttering to herself, weaving, and shaking a finger at someone who wasn’t there. Those walking toward her gave her a wide berth, viscerally and reflexively, one after the other. I would have done the same. Yet she looked familiar, and as I sat in my car at the light, I suddenly wondered if she was the same woman, back in her mysterious world, and I simply could not tell.

So much of medicine is like that—anonymous, thankless, faceless, and uncertain—but necessary nonetheless. This necessity bears reminding, in part because it affirms our better natures, the good we sometimes do despite our indifferences.

I watched her for a while, whoever she was, wherever she was going. Then the light turned green, and I pulled away, and she receded in the mirror and was gone.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

© 2013 by the Association of American Medical Colleges