I am at an advanced age (80) and, though there are disadvantages (I can no longer throw a good forward pass to my grandsons), one of the things I enjoy about my age is that young and old physicians often ask me for advice on career issues. I enjoy that opportunity, which brings me back to my own questions and challenges.
When I was in medical school and for a couple of decades afterward, I and many other physicians before and during their formal medical training, were avid readers of non-technical books about medicine in various formats like biography, essays, and fiction. I wrote about this in a very early column and came across it by accident recently. Although some students and physicians still read about the best values of being a doctor, that practice does not seem commonplace. So here is my small effort to help revive such reading.
A few of these books had a profound and lasting impact on my thinking and values so that even today, decades later, I have vivid memories of the issues, triumphs, and difficulties they addressed. My top three such books: Microbe Hunters by Paul de Kruif (initially published in 1926); Arrowsmith by Sinclair Lewis (1925); and Aequanimitas by Sir William Osler (1904). Don't let the age of these books spook you...truth and passion about our profession never dies.
Of course, the impact of books depends not only on the topic and skill of the author, but also the frame of mind of the reader at that specific time. All three fed my burning idealism, an unformed mixture of saving mankind, practicing medicine with utmost skill, and satisfying my scientific curiosity. These and other books helped move me gradually from seeing medicine as the fantasy depicted by Hollywood in the Dr. Kildare movies to seeing medicine as a vocation, a noble calling.
Microbe Hunters describes the work and the environment of scientists and physicians who explored, opened, and illuminated the world of microbiology. Written for the general public with flair and suspense, a bit like the Western paperbacks of its day, it also has scientific heft and accuracy. I first read it as a teenager when my favorite sections were those describing the work of Louis Pasteur, Robert Koch, and Paul Ehrlich; they still are my favorites. I was and am inspired by the struggles and perseverance of Pasteur and Koch, who laid the foundations of microbiology and its application to curing human disease. Ehrlich strikes a special cord in me for his pioneering search for antibiotics and for essentially establishing the field of chemotherapy. This was dramatized effectively in the 1940 movie, Dr. Ehrlich's Magic Bullet, starring Edward G. Robinson.
Sinclair Lewis's Arrowsmith was dedicated thus: “To Dr. Paul H. De Kruif I am indebted not only for most of the bacteriological and medical material in this tale but equally for his help in planning the tale itself...” I first read this novel during my pre-med years. It traces the career and struggles of Martin Arrowsmith, a physician-scientist in the fast moving, fermenting world of microbiology in the early 20th century. The academic locale is based at the Rockefeller Institute (now Rockefeller University) in New York City, then a world leader in the study of microorganisms and their diseases. I wanted to be Arrowsmith, preventing and curing horrible diseases like plague, fighting the ignorance of peers and the wiles of academic politicians, risking my life to save lives, and tragically and heroically losing my devoted wife to the diseases we fought together in the tropics (the latter no longer seems attractive). It was an inspiring and, yes, heroic way of life.
I was in medical school when I first read Aequinimitas by Sir William Osler and I was immediately captivated. Here was a renowned physician, the first professor of medicine of the Johns Hopkins School of Medicine and one of the founders of the modern era of medicine, speaking directly to me about being a physician, a good physician. The book consists of a collection of Osler's addresses given over the years, many to incoming or graduating medical classes. They were inspiring and made me proud to be a budding member of the profession. But they also were practical, providing advice about how one should behave and what one should value. And most of all, his words rang true, refreshing and clarifying feelings and beliefs that were deeply, if vaguely, held.
The book was an immediate international hit. A section of Osler's preface to the 2nd edition describes the book's reception and intent, as well as his bedrock view of medicine as a calling akin to a religious vocation.
“I have to thank my friends, lay and medical, for their kind criticisms of the volume; but above all, I have been deeply touched that many young men on both sides of the Atlantic should have written stating that the addresses have been helpful in forming their ideals. Loyalty to the best interests of the noblest of callings, and a profound belief in the gospel of the day's work are the texts...from which I have preached. I have enduring faith in the men who do the routine work of our profession. Hard though the conditions may be, approached in the right spirit—the spirit which has animated us from the days of Hippocrates—the practice of medicine affords scope for the exercise of the best faculties of mind and heart.”
But Osler's head was not in the clouds. He continues, “That the yoke of the general practitioner is often galling cannot be denied, but he has not a monopoly of the worries and trials in the meeting and conquering of which he fights his life battle; and it is a source of inexpressible gratification to me to feel that I may perhaps have helped to make his yoke easier and his burden lighter.”
The title address, Aequanimitas, was given to the medical graduates of the University of Pennsylvania on May 1, 1889, his last day at Penn before leaving for Johns Hopkins.
“...my tender mercy constrains me to consider but two of the score of elements which may make or mar your lives—which may contribute to your success or help you in the days of failure. In the first place, in the physician and surgeon no quality takes rank with imperturbability... [meaning] coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of great peril...It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.” He describes this quality in more detail and expresses regret that “some among you...may never be able to acquire it. Education, however, will do much; and with practice and experience the majority of you may expect to attain to a fair measure.”
He goes on to describe the second and similar desirable element. “...the mental equivalent to this bodily endowment [imperturbability is] a calm equanimity. How difficult to obtain, yet how necessary, in success and failure! One of the first essentials in securing a good-natured equanimity is not to expect too much from the people amongst whom you dwell.” He continues that colleagues and patients are full of fads and eccentricities, whims and fancies and weaknesses, “which are not unlike our own.”
Another passage also demonstrates the timelessness of his words despite the passing of a century. “I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.”
Among the 22 addresses are these titles, “Doctor and Nurse,” “Teaching and Thinking,” “Internal Medicine as a Vocation,” “Nurse and Patient,” “The Hospital as a College,” and “Chauvinism in Medicine.” In the latter, he lists the four great features of the profession of medicine—its noble ancestry, remarkable solidarity, progressive character, and singular beneficence.
I will end this quick survey of Osler with several of his well-known quotes and biographical information. “One of the first duties of a physician is to educate the masses not to take medicine.” “Look wise, say nothing, and grunt. Speech was given to conceal thought.” “Live neither in the past nor in the future, but let each day's work absorb your entire energies, and satisfy your wildest ambitions.”
A brief, but excellent biography of Osler can be found at www.whonamedit.com/doctor.cfm/1627.html. The site also has quotes, a list of his writings, and a bibliography of literature written about him. The best major biography of Osler is the Pulitzer Prize-winning, A Life of Sir William Osler, by Harvey Cushing, MD.
I believe there is no better inspiration and influence for medical students, residents and fellows than reading Aequinimitas. But reading Osler—and de Kruif and Lewis—still excites and inspires an old duffer like me as well.
A modern day equivalent of these authors is Atul Gawande, MD, MPH, who has written some wonderful articles on being a better physician: “Cowboys and Pit Crews” was published in the May 2011 The New Yorker, which publishes many of his articles. Several excellent books are Being Mortal, one of my favorites, and The Checklist Manifesto, Complications, and Better.