Last Class

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course,not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

Today was the last academic requirement of my medical school career. It wasn't particularly taxing, simply my final meeting with the professor guiding my last month of reading, but it was rewarding. I had finished reading the two biographies of Osler, along with a volume of his essays and speeches, and then I closed this month of Osler-mania by reading the man's favorite book, Religio Medici, by Sir Thomas Browne.

Much of Osler's writing is directed towards medical students, so in reading his works, I regretted not discovering him sooner. (And if you're a medical student or about to be one, you should drop everything and read Aequanimitas and The Student Life today.) But Thomas Browne is not writing to anyone at all, the work is a sort of confession, as he explores his thoughts on God and life. It is also highly worth reading, and though some parts of it are quite dated, the charitable reader will find much to learn from. Browne was a physician in England, who wrote his book in 1635 (though it wasn't published until later) just before he turned 30. At this point in his life, he had learned 6 languages and studied medicine in all the great schools of Europe. But the book is much more about his relations with God and man than with his profession.

Returning from Browne to Osler, it is easy to see the echoes of the great 15th century doctor in his protege 300 years later. Many of the same thoughts, much of the same style. It is easy, reading him, to see why Osler would state "No other profession can boast of the same unbroken continuity of methods and of ideals. We may indeed be justly proud of our apostolic succession." If the profession is deep, it is also broad, and Osler would say in another place "medicine is the only world-wise profession, following everywhere the samee methods, actuated by the same ambitions, and purpusing the same ends." Both these ideas can been seen, nascently, in Browne.

My question after finishing this three thousand odd pages of reading (two biographies, two collections of essays, and Religio Medici) was "where to now?" Osler brought the "Jovian and God-like" image of the physician in antiquity into the modern era, demonstrating its continuance in a scientific world. But he finished his practice before antibiotics, before most diseases could be cured, and before the era of "informed consent." How does a physician today take the lessons of Osler and transfer them to a modern world? I have reached the end of a class, but not the end of my learning.

My professor's answer was straightforward. Francis Peabody, MD was a member of the generation of medical students growing up under Osler's influence, and he lived long enough to see the new ideas and conflicts start to arise. He wrote an essay called "The Care of the Patient" which at least framed these questions, taking the philosophy of Oslerian medicine and working it into the new world. It is, apparently, worth much more than the famous closing line "for the secret of the care of the patient is in caring for the patient." So I haven't run out of reading material.

5 reasons

I've been tagged with "5 reasons I blog" by Medstudentitis, so here goes.

1. I started this blog to tell stories. At the time it began, I was discovering that even the most indulgent of friends and family tire of graphic descriptions of hospital life. This was a great way to share.

2. In many ways, sharing the odd and amazing stories that form life in a hospital can seem like showing off. It certainly is an enthralling lifestyle at times, and that exultation can be wearisome to those who do not share it. Here, since I know only the smallest fraction of my readers personally, they cannot think less of me for exulting. And most of you know exactly what I mean anyway.

3. Working in a psychiatry ward, as I was back when this started, can make anyone feel they ought to be a storyteller. However, telling the same story fifty times can be trying, and this was a great way to let all my interested friends get the story without exhausting the teller.

4. As I progressed in blogging, I decided to work through some more difficult issues for me, as a developing physician, through this medium. I certainly learned a lot through writing here, especially the three posts "in sickness and in health," "as long as you both shall live" and "Parenthood" which are linked in the sidebar under "Key Posts". Probably others were just as good, but those are the ones that come to mind.

5. Less of a reason why I blog, and more of what's been going through my mind lately: I've been away from the hospital, in the legendary lull of fourth year medical students, cramming what enjoyment they can into the last few weeks of freedom before we all start actually working for a living, and so I haven't been blogging a whole lot in the last month. I've questioned whether I will start again once residency begins July 1, and if I do, what shape that will take. A commenter here a while ago took exception with one of my posts, believing that I was laughing at a patient's expense. Though I wasn't, it caused me to more closely consider the Hippocratic Oath, specifically the line "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal." I'm not sure how much of what I do, and how much physicians do in general, "ought not be spread abroad." Certainly, there is a rather considerable precedent for blogging about the hospital, but precedent does not make ethics. If there are any medical bloggers out there who have actually made it this far, I would truly appreciate your input on the subject. I'm not worried about HIPAA, as I've very clearly stated multiple times that all names here are invented, but I do think law is a poor substitute for societal moral pressure, and I'm trying to determine where that lies here.

Slowing down

Osler was a bit of a bore, truly. I got about 300 pages into the 1200 page behemoth of Cushing's work and decided to switch to Michael Bliss's bio, which at 700 something pages seemed more manageable. Cushing wrote to an audience already familiar with Osler, in an atmosphere of hero-worship. Bliss, though certainly not as accomplished a writer, had the advantage of distance in time from his subject, and gave a perspective I could more easily understand. Still portraying a medical hero, surely, but without assuming I already knew why he was heroic.

But as heroes go, I found Osler more demotivating than otherwise. He certainly had an incredible amount of energy and a singular drive to learn everything he could about medicine. And he balanced his pursuits with reading classics and modern literature, so what's not to love? But I think, upon reaching the end of four years of toil towards an almost mythical end, with "MD" on a paper after my name, that I'm a bit demotivated. Certainly, the end is exciting, but I have to re-examine my motivations for coming to medical school. Most of my friends through high school and beyond wanted to go into medicine, or at least we all said we did. I often point to that as the reason I got here at all: peer pressure. Is that going to be enough to sustain me in residency? Time will tell. But reading about Osler, who published over 700 articles in his lifetime, while writing a textbook that would become the standard work for some 50 years, leaves this particular audience feeling inadequate.

But more than just Osler, my motivation for work has been pretty slim. Given the freedom of a month almost entirely without responsibility, I've been desperately visiting all the museums and restaurants the metropolis has to offer that I've missed in the past years while studying. I've been catching up on reading for fun, sometimes combining the two pursuits, sitting outside some particularly interesting animal's cage at the zoo while poring over the Patrick O'Brian novel I'm finishing. (and as an aside, I find that the higher the animal, the more disheartening the sight of them in a zoo. Fish are fine, and the smaller birds seem to enjoy their large faux-jungle enclosure, but I could see in the eyes of an orangutan the same look I've noticed in depressed patients.) All of this has left little time or inclination towards medical reflection.

I have, however, found a place to live at my residency site, begun packing my things, and started the process of saying goodbye to friends, beginning indolently the next step in this journey. 25 days to go till graduation.

Osler on nurses

As I mentioned a while ago, my current rotation, bringing the fourth year to a gradual, relaxed close, is medical history. I've been reading about Sir William Osler primarily. Osler is probably the most famous clinician of the modern age, and eventually, almost any medical professor will quote him. I am reading about him for that purpose, because despite his fame, I knew nothing about the man before arriving here, and my knowledge was still limited to the quotes heading the various dull sets of PowerPoint slides I've suffered through. When I actually finish slogging through Harvey Cushing's 1200 page biography, I'll write something about that, but since it's been quite some time since I posted anything, I thought I'd put something up.

Osler, I have learned, was a remarkably widely interested and learned man. While a professor at McGill medical school in Canada, he also managed to maintain a professorship in the veterinary school across town, conducting basic research and publishing in both fields, all the while maintaining an amateur interest in microscopic freshwater animals, travelling extensively, and nearly singlehandedly sustaining several professional organizations. (though my source of information is Cushing's biography, which is rather more hagiography at points it seems.) So it is probably unsurprising that a man of such parts should give a graduation address to a nursing school. In a collection of essays I'm also reading, I found the follow example of eloquence which will doubtless be appreciated by the nurse readers here. It may bear mentioning that this address was given in 1891.

If, Members of the Graduating Class, the medical profession, composed chiefly of men, has absorbed a larger share of attention and regard, you have, at least, the satisfaction of feeling that yours is the older, and, as older, the more honourable calling. In one of the lost books of Solomon, a touching picture is given of Eve, then an early grandmother, bending over the little Enoch, and showing Mahala how to soothe his sufferings and to allay his pains...

In the gradual division of labour, by which civilization has emerged from barbarism, the doctor and the nurse have been evolved, as useful accessories in the incessant warfare in which man is engaged. The history of the race is a grim record of passions and ambitions, of weaknesses and vanities, a record, too often, of barbaric in-humanity, and even to-day, when philosophers would have us believe his thoughts had widened, he is ready as of old to shut the gates of mercy, and to let loose the dogs of war. It was in one of these attacks of race-mania that your profession, until then unsettled and ill-defined, took, under Florence Nightingale—ever blessed be her name—its modern position.

The entirety of the address is singularly quotable, which is probably why Osler is so often quoted, but if you are interested in reading the rest of what he said, the full text is here.

How doctors think

A short while ago, while listening to NPR, I heard about this book, written by a doctor who both teaches at Harvard Medical school and writes for the New Yorker. I bought it expecting a grand revelation, because as I understood it, the purpose of the book is not only to explore how physicians think, but to help them overcome the shortcomings of the heuristics used in practice. The perspective I got was that it was targeted at both physicians and patients.

I was a bit disappointed. Perhaps the fact that I am in medical school, in an environment keyed to understanding exactly the concepts laid out here, makes me more informed that the target audience. Certainly, to a layperson, much in this book might be shocking. But to someone behind the scenes, it becomes a set of anecdotes similar to dozens I've heard in the last four years, interspersed with familiar teaching points: maintain an open mind, listen to the patient, consider all the options. The condemnations are familiar as well: insurance under compensates primary care, insurance doesn't cover enough, doctors leap to conclusions. All of which is true, but not new.

In its defense, the book is probably very good for the moderately informed layman, and rereading the laudatory quotes, I see it is not really intended for a physician audience. Certainly, few patients are familiar with a statistic Dr. Groopman cites early in the book, that an experienced physician reaches a diagnosis within 17 seconds of seeing the average patient. Bon mots like that abound for someone who has seen little or been taught little of the workings of a hospital. And the fact that the author is a writer for one of the better-written magazines of our time is evidence of his style and capabilities with language.

Certainly too, the advice he dispenses to patients may be new, and is valuable. Ask good questions, don't be satisfied with cursory explanations, ask what else besides the diagnosis your doctor has settled on could be the problem.

Overall, I enjoyed the book, but my attention was flagging by the final few chapters as it become clear that the exploration of thought was not aimed at a professional audience. The anecdotes serve as warnings and reminders to me, but no more so than any others I've heard. The exhortations to lateral thinking and open-mindedness are no different than that I've heard from my better attendings. And truly, that probably summarizes what this is: an excellent medicine attending writing out his advice to younger physicians in a format a lay audience can understand. Taken for what it is, on that ground, the book is solid and worthwhile. But fellow med students and physicians: don't bother.