Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Friday, September 30, 2011

On the Social Virtues in Medicine

When I look back on my undergraduate education and try and identify what courses were the most useful for how I practice medicine, the answers are not ones that would endear me to the average medical school admissions committee. In fact, I worry about revealing them for fear someone might revoke my license.


Googling a few minutes ago, I see that the accepted course requirements today are the same as they were when I applied for medical school in 1972: a year of general biology, physics, general (inorganic) chemistry, organic chemistry, calculus, and English. I imagine they added English just to demonstrate that physicians aren’t all Philistines.


Organic chemistry? Physics? Calculus? (Note bene on calculus: one semester, the only math course I took in college, aced it, and never looked back. I still like to brag on that.) The mandatory “rite of passage” science courses taught me nothing of value about dealing with or treating my patients. I understand the philosophy behind them well enough. Medicine is a branch of science, and proving you can understand (or at least pass courses in) science probably eliminates a good many incapable of understanding the principles of modern medicine. I get that.


But I have yet to use organic chemistry in a discussion with a patient. I have been dying for 30 years to tell the story of Kekule falling asleep and dreaming of a snake chasing its tail, then waking up and drawing the structure for benzene. In fact, that story is pretty much the only thing I remember about organic chemistry. But the situation has never arisen: I just can’t squeeze it in to an adjuvant therapy discussion, no matter how hard I try. I imagine physics is still valuable to a few of my colleagues in orthopedics and radiation therapy, though I suspect the physics they learned as a sophomore in college bears little relation to the physics they use today.


Even from a science standpoint these courses make little sense. No biochemistry? No biostatistics? No molecular biology? Well, admittedly, there was almost no molecular biology in 1972, but what’s the excuse now? Are oncogenes going away sometime soon? Is the human genome going kablooey? Perhaps one of my colleagues on an admissions committee can tell me why the requirements haven’t changed in a half-century or more, and why they are so ridiculously divorced from medical relevance. Indeed, I wonder how many good doctors organic chemistry has prevented? Far more than it has inspired, I’d wager.


No, the courses I still use were not required for admission.  I took two semesters of Shakespeare.  Reading Shakespeare makes you an instant expert on human behavior: love, hate, greed, passion, grief, joy, and every other human emotion or characteristic one cares to name.  French literature, my other great love in college, served much the same purpose. Balzac, Camus, and Montaigne still teach me a great deal about how I and my patients interact with the world.


Comparative vertebrate anatomy (I was a Zoology major) came in handy later on, but my most useful course was Herb Howe’s “Greek and Latin Origins of Medical Terms,” offered through the Classics Department at the University of Wisconsin. Howe was a professor of classics, not of anatomy. I credit my survival in the first two years of medical school to what he taught me about parsing complex medical terms. He also interspersed wonderful tales of classical mythology amongst his dissections of medical lingo.  Mostly, though, he taught me that medicine was a language as much as it was a science.


We devote a great deal of our time to learning that very foreign language, and once fluent in it often forget our native tongue, and its proper use. What do patients complain about when they are discussing their physicians? Almost always, something like: “I’m sure he’s very smart, but he never explains things to me in language I can understand.” Or “He doesn’t really listen to me.” Or perhaps: “He never takes any time to talk with me.”


Some of these complaints stem from the nature of modern outpatient clinics, which often appear based more on automobile production lines than anything else.  But I suspect the real lesion is more often a failure of what might be called our social virtues.


Recently I came across an article in the Journal of Personality and Social Psychology by Matthew Feinberg and colleagues at UC Berkley entitled “Flustered and faithful: Embarrassment as a signal of prosociality.” In experiment after experiment, the authors demonstrate, those expressing embarrassment in social situations are considered more likeable and trustworthy by others.  They also tend to be measurably more generous. Embarrassment, as a form of “nonverbal apology and appeasement gesture,” serves as a kind of social glue, valuable in making and maintaining relationships.


What an interesting, and counterintuitive, lesson. This is the opposite of what we usually think we should project to our patients.  We assume that we should be forceful and confident, and full of Osler’s prized virtue of “Aequanimitas,” the Olympian calm that makes one permanently unflappable. In many clinics this translates to dogmatism, and the “father knows best” interactions that patients find so condescending and demeaning, even (amazingly self-defeating) in the setting of therapeutic failure. 


I wonder whether the average hospital would be a better place if we required, either in college or medical school, a course in human interactions, somewhere between sociology and psychology.  There is a fair literature on fostering interactions between doctors and patients, on the subtle social clues that further trust and the two-way flow of information so valuable in patient care. Some of these are simple, like sitting down when talking to a patient rather than standing, but the deeper lessons of human interaction and behavior would almost certainly make us more effective physicians.


Historians like to point out that one of George Washington’s prized possessions as a young man -- one he copied out laboriously by hand -- was a book of etiquette entitled Rules of Civility & Decent Behavior in Company and Conversation. There were 110 of them. 


Some are a bit out of date, like rule 92:“Take no Salt or cut Bread with your Knife Greasy.” But rule 110 still works for me: “Labour to keep alive in your Breast that Little Spark of Celestial fire Called Conscience.” Of course, Washington probably wouldn’t survive in today’s Washington. Civility and decent behavior don’t seem to count for much there any more.


Maybe we need some medical equivalent of Washington’s  Rules of Civility for doctor-patient interactions, some easily referenced set of scientifically based yet humane guidelines. Some of what we call “bedside manner” is inherent in our personalities, but some is teachable. 


Maybe even the appropriate role of embarrassment. Getting back to the virtues of embarrassment: I was speaking to a medical student at the end of her rotation with me a few years ago, passing on my philosophy of life, such as it is.  I told her that one of the secrets to happiness was to be unafraid to look silly every now and then.  Without dropping a beat, she replied “Well then, Dr. Sledge, you must be one profoundly happy man.” And then, a few seconds later, realizing what she had said, she blushed bright red.  She’ll make a great doctor.