Archive Page 164

Signed, Harvey Cushing

A couple of birthdays ago, my wife wanted to buy me a book by or about William Osler. She had watched and listened as I read from his book on the history of medicine and as I searched online for quotes by him.

We had both heard of Harvey Cushing’s biography of Osler. On one of the larger online booksellers’ websites, she found the only available set at the time of this two-volume work, and ordered it.

A week or so before my birthday, I was on the phone with her during my lunch break when she opened the package. Of course, I didn’t know what she was doing. All I heard was the rustling of paper and then her words:

“Oh, my gosh!”

On July 18, I said the same thing when I opened volume one. There, on the first page, was a flowing inscription in brownish-black fountain pen ink, signed “Harvey Cushing”. The books were not sold with this fact stated, and would have fetched thousands of dollars if they had been.

This biography of the father of American medicine, written and signed by the father of modern neurosurgery, is a source of inspiration I often return to. It provided most of the phrases I used in my 2011 post “A Christmas Message to All Physicians from Sir William Osler”.

Osler, our continent’s foremost internist, may be many physician’s imaginary mentor, but Cushing was quite a man himself, and was America’s most renowned surgeon. He introduced blood pressure recording to the United States, for example. He became a professor at age 32, pioneered brain research and neurosurgery, described the disease we now call Cushing’s Disease, wrote 14 books, only 9 of which were about surgery, and earned honorary degrees in literature, science and the arts. After reaching the mandatory retirement age of surgeons in Massachusetts, 63, he continued to teach and also worked extensively as a military surgeon.

Thomas P. Duffy, in a 2005 article entitled “The Osler-Cushing Covenant”, writes about the two men:

“In 1900 William Osler established a friendship with Harvey Cushing that encompassed the personal and professional aspects of their lives for over two decades. Their shared participation in the covenant of medicine shaped an intense friendship and mentoring relationship that profited both individuals immeasurably. The choice of Cushing as the recipient of Osler’s mentoring had its origins in their rearing, avocations, and in the way of life that they shared. In Cushing, Osler identified a surrogate son who joined with him in defining the course of medicine and surgery over the next century.”

Osler, twenty years older than Cushing, opened his home to Cushing, as he had done to many other students, but with Cushing, the friendship also included Cushing’s young wife and their children, who knew William and Grace Osler as Aunt and Uncle.

In a twist of fate, Osler’s own son, Revere, born around the time Osler and Cushing first met, was critically wounded at age 21 in World War I, and was taken to a field hospital where the surgeon on duty was Harvey Cushing. Revere’s life could not be saved, and every year on the anniversary of his death, Osler wrote to Cushing, expressing his relief that his son had died in Cushing’s presence.

At Osler’s funeral, Cushing delivered a eulogy, in which he referred to Osler as his “spiritual father”. Osler’s widow then asked him to write her husband’s biography, a task that took him four years to complete. The 1,400 page book earned him a Pulitzer Prize in 1926.

Two quotes by Harvey Cushing speak of his own compassion and optimism:

“A physician is obligated to consider more than a diseased organ, more even than the whole man – he must view the man in his world.”

“The capacity of man himself is only revealed when, under stress and responsibility, he breaks through his educational shell, and he may then be a splendid surprise to himself no less than to this teachers.”

Of Osler, his mentor and father figure, Harvey Cushing writes:

“He advanced the science of medicine, he enriched literature and the humanities; yet individually he had greater power. He became a friend of all he met – he knew the workings of the human heart metaphorically as well as physically. He joyed with the joys and wept with the sorrows of the humblest of those who were proud to be his pupils. He stooped to lift them up to the place of his royal friendship, and the magic touchstone of his generous personality helped many a desponder in the rugged paths of life. He achieved many honors and many dignities, but the proudest of all was his unwritten title, the Young Man’s Friend.”

Words of a son; signed, Harvey Cushing.

Pain and Suffering

“Suffering ceases to be suffering in some way at the moment it finds a meaning”      Viktor Frankl

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has”      William Osler

 

Back in the 1990’s when pain was the newest vital sign, physicians were mandated to treat it, often with powerful medications and without truly understanding the cause and significance of the pain for individual patients.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

Of course, pain was never measured objectively in antiquity or when it became a “vital sign” a couple of decades ago. It still can’t be measured, which makes it no more of an objective clinical sign than someone guessing their temperature without a thermometer.

“Pain and Suffering” is a legal constellation that equates the significance of the two afflictions; doctors, however, have wanted to think of the two as separate, one or the other, treated differently. In many instances, doctors treated only one – the one we call pain – and skirted around the other. We have pain specialists, but perhaps only end-of-life care formally addresses suffering; it is seldom a topic in everyday medicine.

How many times, when a patient has said “I hurt” have I asked “where” instead of “how” or “tell me more”, assuming the Chief Complaint is physical.

How many patients with chronic pain are unrelieved by our usual pain medications? And how many of them receive the label “psychosomatic”, but little help from their doctors?

A few weeks ago, I came across a short piece by Dr. Thomas H. Lee in The New England Journal of Medicine about suffering. I have continued to think about it ever since.

I think medicine embraced pain assessment and pain treatment in a way that overcompensated for our ineptitude at mitigating suffering. Even as we treat patients’ pain, we sometimes cause suffering through the dehumanizing way our clinics and hospitals work.

Eric Cassell describes suffering as something that happens when our personhood is threatened. Sometimes physical pain, disability or the threat of dying is the cause of suffering, but sometimes the threat to personhood is loss in other spheres. In order to alleviate suffering, physicians need to understand something about the nature and meaning of this threat.

Doctors in our era are trained to treat diseases. We are not often formally trained to explore the person with the disease; this is something we are left to discover on our own, when the disease paradigm doesn’t seem to fit the patient we are trying to help.

The movement we now call “narrative medicine” is focused on the subjective meaning of disease and suffering. It offers a way out of the mechanized mindset of evidence-based medicine that is built solely around the lowest common denominators of diagnoses and treatments. The corporate-scientific medicine of today dismisses the statistical “outliers” and individual variations between patients in its efforts to help the greatest number of individuals, instead of each particular patient in the physician’s exam room.

Doctoring is a personal calling, built on personal relationships. Even statistical outliers deserve health care that works for them, and suffering can never be understood or mitigated without first seeking knowledge of the suffering person’s own fears and beliefs.

Eric Cassell writes:

“The doctor-patient relationship is the vehicle through which the relief of suffering is achieved. One cannot avoid ’becoming involved’ with the patient and at the same time effectively deal with suffering.”

How many doctors are comfortable getting that involved? And how many health care organizations see that as the role of their physicians?

Twenty Questions

Adrian Bell didn’t look dehydrated, but his diarrhea had come and gone for a week and a half when I saw him a few weeks ago.

“Is anyone else sick with the same thing?” I asked, beginning my usual line of questioning.

“No”, answered Eleanor, his wife.

“Have you had any water to drink from a new or unknown source, or have you traveled away from home?”

“No”, both answered in unison.

“Any new foods that only you ate or that you don’t normally eat? Are you a big milk drinker?” I added, thinking about secondary lactose intolerance.

Still, negative answers.

“Any chills, fever, belly pain…” my questioning continued.

Nothing.

“Have you had any antibiotics prescribed by any other doctor?” I asked, because we have had a flurry of Clostridium Difficile infections in our community, which is something we didn’t have to worry about years ago. We had three cases recently at the nursing home, where Eleanor volunteers.

Still, “no”.

“Anything else going on, even if it seems unrelated?” I finished my questioning as I motioned for Adrian to get up on the exam table.

“I have had some joint pains”, he answered.

After an unremarkable physical exam, I ordered some lab tests, including inflammatory markers, a stool culture and C. Difficile test. I gave dietary instructions and we set up a follow-up appointment for a few days later.

At his follow-up visit, everything was the same and all the tests were normal. I sighed internally.

“Do you think it may be Beaver Fever?” Adrian and Eleanor both leaned towards me. “We’ve heard of an awful lot of people downstate who’ve had that.”

“I haven’t seen a case of giardiasis around here in years. How do you think you may have gotten that?”

“Well, two weeks before this started, I fell in a beaver pond in the woods in back of our property. I was checking out an old four wheeler trail….”

“Fell in a beaver pond…” I kicked myself for not having ordered a test for ova and parasites, but, of course, they can be unreliable.

“I think we’ve got to put you on some medication and do another stool test”, I said, thinking to myself that I now have one more question for future diarrhea assessments.

Medicine is like twenty questions sometimes. If you don’t ask the right questions, you don’t get the right answers.

When the Doctor is the Treatment

“To prevent disease, relieve suffering and to heal the sick – this is our work”        

                                                                                          William Osler

“The function of meditation practice is to heal and transform”        

                                                                                         Thich Nhat Hanh

I am not a terribly outgoing person, but more than occasionally in my day as a rural physician, there are expressions of joy and gratitude, hugs and pats on shoulders, moist eyes, failing voices and pensive moments of shared silence. I am never good at small talk in social situations in general, but in the exam room, I always seem to know what to say, no matter what the situation is.

It is as if my role as a doctor gives me the courage and inspiration to “be” the healing presence my patient needs in that moment. It is not an act, but more like being carried by a force that hones my senses and guides my efforts.

Medicine involves archetypal relationships, as there have been sick persons and healers through all of human history. Physicians embody an apostolic profession, with knowledge and wisdom passed on between generations of physicians since Hippocrates’ era.

In our lifetime, these aspects of medicine have been forgotten, ignored or disputed by many, but today’s neurobiology has brought them back into the discussion of what physicians are to their patients.

Eric Cassell, in his book “The Nature of Suffering and the Goals of Medicine”, tells the story of an asthmatic physician, whose disease was out of control until a wise physician treated him as a patient instead of a colleague:

“A physician I know told me about the treatment for his asthma. He was taken care of by a wonderful chest physician whose skills he had seen demonstrated many times before and since. He was on high doses of prednisone (a cortisone like drug) and other medications for many months but he could not seem to get off the drugs without getting sick again. He would meet his doctor in the hospital corridor and ask what to do next. The doctor-patient did what was suggested but to no avail. His own knowledge of asthma was not inconsiderable but that was no help either. He told me that he could not get his friend and colleague to treat him like a patient. Finally, desperate, he went to another doctor whose specialty was asthma. The new physician promptly made my informant into a patient. He told him what to do (what he said seemed the same as what had been previously tried) and scheduled office visits frequently and regularly, and within six months my friend was off all medication. What was the difference? It was not the medications or their schedule – they were the same (at least at the start). The difference, I believe, was that the second physician made him become a patient. Once that happened, the new doctor was able to begin “pulling strings” inside his doctor-patient’s body. No one knows how this comes about or how the physician is able to have an influence on the patient’s illness apart from explicit medical or surgical treatments, but this is the process involved. Current research is increasingly revealing the influence of thinking on immunity and other body functions, so there should be little surprise that doctors are also able to affect the patient’s physiological process. No one doubts that doctors have an influence on their patients’ mental processes – we are of a piece, and affecting one part alters the whole.”

The first physician gave competent clinical advice, but the patient was not helped. The second physician embraced the role and responsibility of the healer. He created, or entered, the space (metaphysical, meditational, Divine, Reiki – or quantum physical if you will) where healing is possible.

Hippocrates said these words 2,500 years ago, and modern science is now realizing the truth and wisdom behind them:

“Natural forces within us are the true healers of disease.”

All we do is facilitate.

Doctors Without Heroes

A few years ago, a medical journal piece about electronic medical records with built-in “decision support” announced that the days of super-physicians and master diagnosticians were over.

Being a doctor isn’t very glamorous anymore, and being a good one seems rather obsolete with so many guidelines and protocols telling us what to do.

A hundred years ago, William Osler, a practicing physician, had single-handedly written the leading textbook of medicine, reformed medical education, helped create and chaired Johns Hopkins and become the chair of medicine at Oxford.

Today, it is virtually necessary to be a researcher to teach at a university, let alone chair a medical school. The only other way to advance in medicine is to go into administration. Leaders in medicine are not chosen for their mastery of clinical practice, but for their managerial or business acumen.

The culture of clinical excellence has few heroes in our time. Pharmaceutical companies sometimes speak of “thought leaders” on the local level, which is more often than not only their way of building momentum for their drug sales through promoting early adoption of new medicines. Doctors today practice on a level playing field, where we are considered interchangeable providers in large organizations and insurance networks. Media doctors don’t earn their position based on clinical mastery, but rather their communication and self promotion skills.

What happens to medicine when it has no heroes? Who defends the ideals of a profession that is becoming commoditized? What keeps new physicians striving for clinical excellence with only numerical quality metrics and policy adherence as yardsticks? How are the deeper qualities of doctoring preserved for new generations of doctors, and how are they kept in focus with all the distractions of today’s health care environment – because people still worry and suffer; they are more than bodies with diseases or abnormal test results.

Every day, doctors on the front lines treat two dozen fellow human beings with every imaginable condition. How do we carry on, with only our own ideals as beacons in the fog, if we are left to ourself to defend our higher purpose, without champions, mentors, or heroes?


I just realized none of the posts show on an iPad or a computer, but they do show on an iPhone. WordPress is working on this. In the meantime, please visit my Substack.

 

 

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

 

BOOKS BY HANS DUVEFELT, MD

CONDITIONS, Chapter 1: An Old, New Diagnosis

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