Thanks so very much, Professor Marty. This is a wonderful evening for me. In the first place, it’s a great honor to be back at the festival again. It’s an added honor that Martin Marty has introduced me. Martin Marty’s life has meant so much. His life’s work has meant so much to so many of my bio-ethical colleagues that just the opportunity to lay eyes on him is an honor, as a matter of fact.
But the ultimate honor, really, is that this is the Franke Lecture in honor of Rich Franke, who has done so much, not just for the city of Chicago, and for this festival, but for Yale in the matter primarily, I think, of his guidance, and his wisdom, and a certain philosophical nature that, to my mind, manifests itself, most importantly in his understanding that there should be no breach between the sciences and the humanities. And I think he’s going to be spending the rest of his life, until he finally decides to shuffle off this mortal coil, doing something about that at Yale. In fact, so much is he inclined to do that that he’s bought a house which is less than half a mile from my own. So maybe we can commune about these situations.
This is the first talk I’ve ever given where nobody asked me the title. I can only assure you of one thing, this may be the Franke Lecture in Economics, but you’re not going to hear very much about Economics. I’m one of those people who has always had trouble balancing his checkbook, that kind of thing. If I were to give a title, though, I would give it the title of a project that I’ve been working on researching for about a year, and that is The Goodness of the Physician.
When I talk about the goodness of the physician, I don’t mean what the ethicist usually mean. I don’t mean things like understanding autonomy, and understanding justice, and beneficence. I’m talking about, actually, the moral virtue that makes a difference in a physician’s ability to treat his or her patients, those who come to us for healing. I’m going to start way back with Hippocrates, about 350 years before the Common Era. We don’t know much about Hippocrates. We only know that we know a little about him, that the – when we say Hippocrates we mean a large number of physicians who belong to this guild that we call the Hippocratic Guild. They existed from perhaps 350 before the Common Era to about 150 before the Common Era, and they completely changed the face of medicine on the Great Peninsula and into Asia Minor.
Some of the things that they did are worth reviewing. The most important thing that they did was that they differentiated about the cause of diseases from what had been before. Before if one got a disease of any consequence – malaria was common at that time, smallpox – pox we recognized was common, tuberculosis we recognized was common – that if – it was thought that if one became sick with one of these serious diseases the gods, Apollo or whoever, was angry and something had been done by the patient that allowed him to deserve this. In fact, this was really the position taken by the Catholic Church during the Middle Ages.
When the Hippocratic physicians came along, they really couldn’t agree with this, and they made the point – and they made the point in all of their writings – and we’re talking about something like 70 books that were written in total over the course of this 200 years – they made the point that when one is sick something in nature has made one sick. Whether one has too much of a particular fluid in one’s body, or a little, it can be treated by natural causes. No longer were people to pray to the great god of healing, Asclepius, or to his two daughters, who had a couple of interesting names, Hygeia and Panacea. So here we are, just read a little Greek and you learn etymology.
So they separated health from the influence of the gods, both by virtue of how one got sick and how one was healed. One no longer went to the Asclepian temples, one went to these physicians who did some remarkable things. One of the things they did was to keep records. Physicians had never kept records. When they kept records of each patient they could then write these books, these 70 books, and pass on to generation after generation – the way we do now – what they had learned. What they learned had to do, not just with taking a careful history which nobody had ever done before, but really doing a physical examination.
They would put the ear to the chest and listen to the noises that they could hear in the chest. They would feel the abdomen. There was something called the Hippocratic facies, which was the face of someone who was close to dying. That was important because one of their other contributions was what we call prognosis, predicting what would happen. They studied their books, they listened to their teachers, generation after generation, and when they came to an area they would let people know whether treatment was appropriate or no treatment was appropriate because they could do this thing, they could prognosticate.
But I suppose in addition to separating medicine from the gods and bringing it where it belonged, to natural influences, their biggest contribution was their ethical sense, their code of ethics. I’m not talking only about the Hippocratic Oath, which we all know about. Their code of ethics is seen in almost every one of these 70 books that we have been studying for hundreds of years trying to find out what these doctors were really like, and what we have inherited from them, and what we have lost of that inheritance.
Now these books that I refer to specifically that really had to do mostly with ethics where it named things like the law on decorum, the physician, what he is to be like, and precepts. I want to read a few of them that I’ve scribbled down here on my antifreeze – what else can I call it – because I didn’t want to forget what they were. One of them, “With purity and holiness I will pass my life and practice my art”. Purity and holiness. These are personal moral virtues. They don’t have to do with ethics, which is really a negotiated kind of way of living.
Here’s another one, “Where love of mankind is –” Love. I don’t see the AMA code having the word love in it anywhere, which is possibly why only 1/3 of American physicians belong to the AMA. “Where love of mankind is there is also love of the art”. They called medicine ‘the art’. It never occurred to them that healing people was anything but a great art, perhaps the greatest of the arts, that the Greeks indulged themselves in.
My favorite – and my favorite really to the point where this project of mine has become named for it – is this one, “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician”. The goodness. We’re talking here about virtue. We’re talking about compassion, about honesty.
I know there are doctors here this evening, and nobody is near my age, but some are old enough to know that they have had experiences in which there is something about the relationship, something about transposing their own moral values in the sick room that has made a difference in a patient’s recovery. I want to tell you a story, because this is the most dramatic example of it I’ve ever encountered, and it happened to me. Here we go.
The year is 1963. The Chaplain of Yale University – and his name will be familiar to a good number of people here – is a remarkable fellow named William Sloane Coffin. William Sloane Coffin was one of the earlier civil rights authorities. Perhaps every month he would go down to Georgia or Mississippi and be involved in some activist movement. He was not infrequently jailed. A couple of times each year he’d end up in jail. In the year 1963, he came back from a dank Mississippi jail sick as hell. He had a fever of 103, he had on his chest x-ray a completely whitened left chest, which meant that his left chest was filled with fluid, and he was sick as a powerfully built man can be. He’d been in the OSS in the War, and even though he was a spy he had seen plenty of combat, and he was physically as brave as he was morally.
So there he is on the medical service for a week, for ten days, for two weeks. Every day, every evening, his temperature hits 103, 102, and they’re putting needles in his chest. They’re trying to get a sample of the fluid so they can culture it, or at least get the fluid out so his lung can expand. And what do internists do when they get really desperate? They call a surgeon. So they called me because I was a young surgeon. He was relatively young at that time, older than I was, but they called me and I was pleased to be called because I knew that I could get fluid out of that chest. You know, that old saw, “They said the job couldn’t be done”. He smiled as he said, “I’ll do it”. So he took the job that couldn’t be done and couldn’t do it. Well, that was essentially what happened to me. No matter where I stuck this needle – and it was a pretty big needle – I couldn’t get any fluid, and he was getting sicker and sicker, and the flesh was figuratively falling off his bones.
One day I said to him, “Reverend Coffin, there’s an operation you’re going to have to have. It’s called a decortication”. Decortication involves a wide opening of the chest and taking off this thick layer of inflammatory tissue that is compressing the lung. You peel it off the lung, you peel it off the chest wall. It’s a very bloody operation and it’s about as bad a horriblectomy as we ever do. It’s got a very high mortality rate. I told him that, and he was very stoic about it.
It was scheduled for Thursday morning. My operating days at that time were Tuesday, Thursday, and Friday, and I went to see him on Wednesday evening. I’d seen him in the morning, his temperature was a little high and I knew that that evening it would be high. Lo and behold, he had no fever at all. First time in the three weeks he’d been in the hospital. I thought, “Well, something very strange about this”. He is, after all, a minister, so who knows?
So I cancelled the operation for the next day thinking I’d see how he was, and I rescheduled it for the Friday, thinking one day would give me enough time. He never had an iota of fever on Friday, never had any fever again. Well, I followed him in the hospital for another week, ten days, and then I stopped following him because I was, after all, only the consultant. I never saw him again for two years. Our paths just never crossed. I had no idea what had happened. This defied everything that I knew from my careful scientific training.
Two years later he was the officiate at a faculty wedding to which I was invited, and afterwards I cornered him. It was a very noisy room, you know what wedding receptions are like, and I said, “Reverend Coffin, you’ve got to tell me what happened.”, as though he could possibly tell me, but he could tell me. I said, “How did you get better?”. He looked at me and he said – these were his exact words – “I did it for Bizaziro”. “What?”. “I did it for Bizaziro.”, he insistently said. At first I thought he was saying, “I did it for Beelzebub”. He’s a New England divine, and who knows who he might have been trucking with. He said, “I did it for Bizaziro”.
Suddenly I realized what it was. Bizaziro was the intern who was taking care of him, and every evening, whether Joe Bizaziro was on or off – in those days we were on most of the time, the house officers were – he would come in and talk to Bill Coffin about philosophy, about religion, about baseball, about music, and they developed this very, very close bond. Then he said to me, said Bill Coffin, “I did it for Bizaziro. I couldn’t let him down”.
Now once again, I’ve seen forms of this in my practice over the years, but I’ve never seen anything as dramatic as this. He did it for this wonderful young intern who went on to become a wonderful physician over the years. He’s retired now, but he had a career that one can only look to with pride. So these things do happen. Well, we now know from our friends who call themselves the psychoneuroimmunologists that there are very good immunological reasons why every once in a great while such a seeming miracle does occur. Again, one sees it rarely in a career, but one definitely does see it.
In my own hometown of New Haven, which is heavily Catholic – and just WASPy enough so there are some Protestants around – just before Christmas every single year the obituary lists drop and on December 27th they start going up again. Every year, never fails. I have some New Haven people, one of whom is my roommate, and she’ll tell you – my wife will tell you that this is absolutely true.
So what is going on? Well, the Hippocratics would have said this has something to do with the goodness that Bill Coffin not just intuited but saw within his physician and his desire to get better.
Well, this set of Hippocratic teachings was finally codified in the second century, and it was done by a man named Galen who was so authoritative and wrote so many books that medicine didn’t really change for about 1,400 years. It took that long for medicine to change among the Christian nations of Europe. But within a few hundred years Mohammed had been born. Rome fell, as you remember in 476. Mohammed was born 570 something, so that by 700 the Muslim nation – which started with a Renaissance, unlike what we did, had to wait all this time – started with a Renaissance.
The Muslim nation was sweeping across North Africa and Southern Europe, and they had essentially taken over the Greek teachings. The Greek teachings, which included the importance of the goodness of the physician – I won’t go into the details of what the Catholic Church did during the Middle Ages, but medicine in the hands of the Catholic Church, for a group of reasons, did not thrive.
So we find that the Greek teachings were translated into Arabic, and who spoke Arabic? The Muslim physicians did, and many Jewish physicians did, all the North African Jewish physicians did. We come across names like Avasanar, Razis, Ibukasis, Mimonodes, Haliabus, Ibinophius. Some of these names are familiar. What they did was preserve among themselves the notion of that personal morality, the importance – when there was really very little else they could do, they had herbs and this kind of thing, almost no surgery – the importance of the image that the doctor presented to the patient.
Well, this went along very well until the 15th Century when Constantinople fell. The Muslim Empire was essentially destroyed in this short period of time, but many of the Greek texts had been transferred from Rome where they were kept to Constantinople, so they became available to Europe. I’m cutting a lot of things short, as you can imagine. This began the Renaissance. Of course, you’ll recall learning in junior high school that the Renaissance was characterized by two things: One, a return to the values of the Greek and Roman civilizations, and a fascination and an interest with the human being, most particularly human anatomy, the human body.
Well, this manifested itself within 100 years by some interesting work in anatomy. A man named Vesalius did the first really major, huge, real dissections of the human body, taught all Europeans anatomy in a book that he wrote. William Harvey, about the time the Pilgrims were arriving here, published a book, the year was 1628, describing the circulation of the blood. He also essentially created the notion of inductive reasoning, although Frances Bacon gets the credit for it. He brought it to be among physicians.
In the 18th Century, a man named Giovanni Morgagni did 700 dissections and he correlated what patients came in with, their complaints, with what he found inside the body when he did autopsies on these patients when they died. He was the man who conceived of this wonderful phrase, “Symptoms are the cries of the suffering organs”. That got a lot of people excited.
Here it was, it was the late 18th Century, and in the late 18th Century the French Revolution occurred, French medicine was overcome by a great revolution, and instead of the old stuffy way of appointing only the nobility to important posts, people of considerable intelligence and background could become appointed to professorial positions.
The way they taught was to make rounds in the great French hospitals – collectively historians call them the Paris hospital. Although there were about ten of them, it was all called the Paris hospital. Americans, Germans, Italians, even Russians, Spanish doctors came to study there. They would make rounds, and there wasn’t much they could do. Not only that, they didn’t want to do anything. They were only interested in correlating patients’ signs and symptoms, the results of their examination, with what they found at autopsy. So it was even in the doctors’ scientific interest that patients die. Many of them did. Many of them did. This was before malpractice laws. Didn’t we have a Presidential candidate who made a few million dollars – or a few hundred million dollars – doing malpractice? A fellow named John Edwards. Well, in any event – so you see they’re no better now than they weren’t then.
So the concept, again, of what we call now – historians call – therapeutic nihilism. We will not do anything to treat anyone because the important thing is to study their bodies when they died. Studying their bodies was not as easy as it might seem, because we had none of the diagnostic studies, the tests that we have today. The first important diagnostic tool was invented on a single day in the year 1816 by a French physician whose name was Renee Theophile Hyacinthe Laennec. Bad enough his middle name should be Hyacinth, he was also five feet, two inches tall, and very shy. At the risk of making value judgments, I’ve seen plenty of portraits of him, a really homely Frenchman.
He was the chief of the chest service at a hospital, at that time, in the suburbs of Paris, the Hospital Necker, N-E-C-K-E-R, and he was making rounds, as he did every afternoon, and examining patients, showing his students and his retinue how this was done, hoping that there would be an autopsy on each patient, essentially knowing that there would be, and he came to the bed of a woman newly admitted. She was a young woman, about 19 or 20, intimidatingly pretty, buxom, and filthy, as all patients were at that time. The French in those days bathed – they were bathed at birth, they bathed the night before they got married, and their bodies were bathed when they die. Those of you who have recently been on the Paris Metro may think it’s still the same.
In any event, he did not want to put his ear under this young woman’s voluptuous breasts. He was very nervous and skitterish, and he said, “Well, we’ve done enough today. The rounds are over”. He went home and dismissed all of the people in training, his students, and he started walking home, and he came to the courtyard of the Louvre, which at that time was a palace, and he saw some boys playing a game that he used to play when he was younger. They take this long two by four, about eight feet long, and one boy at one end would scratch a signal, a pre-arranged signal, and the kid on the other end would listen to see if he could interpret what these letters were.
Little Laennec looked and said “Sacre bleu” or something like this, and he hailed a passing cab. I guess it was a Cabriolet. He goes back to the hospital, and he rolls up a notebook – he described this in the book that he published in 1819, three years later – he rolls up a notebook and he listens, he’d invented the stethoscope.
The first stethoscope were called baton or cylandre, and they came in two parts. You’d unscrew the two parts, put them in your hatband, and go make a house call. When he invented the stethoscope there was a tremendous amount of discussion about it. Some doctors who bought stethoscopes – which cost 13 shillings at that time – no, you got the book and a stethoscope for 13 shillings – said, “I can’t hear all the sounds he describes”. Others say, “Oh, I hear too many sounds. I can’t figure this out”. Some said that the stethoscope would intimidate patients. Some said it would get patients all excited and they’d think more of physicians.
One thing was said by a few far-seeing physicians. They said, “This will change the face of medicine. This will change, essentially, the goodness with which we used to be viewed”. They already knew they weren’t being viewed that way anymore. “It is the first thing we have that puts a physical distance between us and the patient, and it is a metaphoric distance”. Well, you all know that later the stethoscope, of course, was divided into this thing that kids carry around their necks on TV shows, and George Clooney has made so popular for us. In the good old days we kept them in our pockets, but now you’ve really got to show this phallic symbol of authority.
It started with that. It started in the early 18th Century, that distancing. Later in the century, the cell theory came along in the year 1839. The notion of anesthesia was invented by a couple of entrepreneurial dentists in the year 1846, the only thing that anyone in America had added to medicine. America was really in a very backward state medically. France, during the early part of the century, was the leading medical country, then Germany from about 1855 onward. Antisepsis was discovered by a combination of the work of Louis Pasteur and a man named Joseph Lister in 1867. X-ray came along in 1895. Increasing, increasing technology.
The remarkable thing about all of this technology and all of this distancing at that time was that it occurred within the hospitals and teaching centers. If you went out in the periphery your family doctor was very likely still to have a real relationship with the family, with the patient, but the academic physicians less and less and less.
Well, the big problem for us in America was that we were, as I say, very far backwards in medicine. Our young people would travel to Paris, would travel to Berlin and Prague, Baron, all the German speaking cities. Vienna was a major draw – to study there. They didn’t just go there for two weeks. They didn’t just look over someone’s shoulder in the OR. They would spend six months, a year, doing research. The leading American physicians were all German trained in one way or another. The great William Osler of Johns Hopkins used to complain that too many doctors are what he called, “Deutched”. They’re Germanized.
The German physicians, in the late 19th Century and early 20th Century, were the epitome of therapeutic nihilism. They were the epitome of laboratory people, not clinical on the wards, but all of those contributions, the contributions that were made by names very familiar to you if you were to see them listed, were made through the microscope, and with culture materials, and things like this, but they were not bedside contributions. In the meantime, out in the periphery, away from the great centers, you could still go to a doctor who knew you well and understood you.
Well, a lot of people in the United States became very disturbed about this huge exodus of young people who would then come back to America and essentially control academic medicine. They were disturbed about the sad state of American medical education. We had, between ourselves and Canada, 155 schools. The vast majority of those schools were called proprietary because they were owned by groups of doctors. I and my friend, Irving, could open up a school, and we would charge people money for it. We had a microscope to show some of the students something. Most of our laboratory equipment wasn’t even stuff that we knew how to use.
So along came Andrew Carnegie with all of his millions and he said, “Let’s do something about this”. So they hired a young man – well, he was in his 40s – named Abraham Flexner, who had done a study of American colleges actually called The American College, and they said, “Look, we’re going to give you all the money you want. We want you to visit every medical school in the United States and tell us which ones should be saved”. So here are 155 schools between the two countries, most of them within our borders, and he comes up with a figure that only 35 of them are worth saving.
Well, along comes Rockefeller, creates something called the General Education Board, and he says – the Rockefeller Group, Rockefeller Foundation – it may not have been called the Foundation at that time – said, “We’re going to give you $50 million dollars”, and later other philanthropies came on board, and there were hundreds of millions of dollars available, and this year, 1910, when Flexner wrote his report – “We’re going to give you all this money and you’re going to go out and bribe the deans and the boards of directors of those 35 schools to become like Johns Hopkins”.
Johns Hopkins had been founded on the German principle, the principle that science is paramount, which, of course, still occurs today at Johns Hopkins and elsewhere, and that directors of departments will be clinical scientists, and their focus will be not just learning at the bedside, but learning in the laboratory. With that, Flexner essentially created the model that we have today. He started that pendulum going from where it was over on the left hand side, all the way to the right. So from then on academic physicians were largely appointed, and kept in their appointments, on the basis of their laboratory contributions.
Fast forward a hundred years in my own school. The chairman of every major department has been chosen not for clinical skills but for the number of papers written, and the scientific work. You know about MRIs, and FMRIs, and CAT scans, and who knows what. You know that every kid who comes in with appendicitis gets an ultrasound, whatever that may cost, even though the frequency of misdiagnosis was under 15% without the ultrasound, and most doctors had a pretty good idea they might be wrong on that other 15%. Clinical skills, the ability to do what the Hippocratics taught us to do, a physical examination and history, that ability is taught a little bit. There is some lip service paid to it, but not very much.
We live now in what I call the age of the image. When many of the physicians who are here this evening were in training they were taught to be masters of the physical examination and the history. Now young people are taught to be what we might call masters of the menu. A brief history is taken, “Oh, let me look at my algorithm. He has a bloody cough. We should do this study. If that’s positive, we do this study. If that’s negative, we try this study, and that will be positive so we’ll do that.” Eventually you get to the operating room, the surgical consult who solves everything, and now this surgical consult is solving everything through a kind of a telescope that he sticks in through a hole or two and everybody goes home in two days. You know the recidivism rate is something that has been a big problem. It never was a huge problem until about 30 or 40 years ago, but it is now.
So we live, essentially, in the age of the image, of the x-ray, of the MRI, of the functional MRI, of the SPEC scan. We make our diagnoses through imaging, we make our diagnoses through other laboratories, whether they’re studies of the blood, or studies of various kinds of tissues. Our young people nowadays in training are not allowed to work more than 80 hours a week, so it is very difficult for them to follow a patient long enough to truly understand the progress of a disease.
Medical schools have been worried about this, and they’ve been worried about it for 15 or 20 years. They’ve had solutions. One of them is to try to return to Hippocratic idealism. It’s quite a jump to leap back more than 2,000 years when the teachers themselves haven’t been trained in this notion. There have been, from time to time, some people shouting in the wilderness about these problems. The famous quote by a man named Peabody in 1921 to a group of Harvard medical students in which he said, “The secret of caring for the patient is caring for the patient, caring about the patient”. There was a famous clinician actually at the University of Vienna who was very fond of saying that nobody can be a good physician unless he – or she, women were coming into medicine in 1895 – is a good person.
So this hearkening back to those days was something people were beginning to yearn for. The problem is you can teach ethics, and you can teach professionalism to young people. The only time in the medical curriculum that’s available for them is in the first and second years. Once they get on the wards, once they get on the clinics, the excitement – and this is something I’ve written about, as many of you know, extensively, especially in that book How We Die – the excitement of taking care of patients, the moment to moment moments takes away any thought of interpersonal relationships. Dealing with families has become relatively superficial. Hospice was founded in 1967, as you all know, by Cecily Saunders. There’s a big hospice movement – not nearly enough. There’s a big palliative care movement, and to this day there are only 1,300 certified palliative care physicians in the United States who bring to a bedside the kind of thing I’m talking about.
So what can we do? What can we do when we have more distance and more technology than ever? I propose – it’s radical – I propose a new Flexner study. I think it can be run by the Institute of Medicine. It will take, not Flexner, but perhaps 100 people in various medical specialties, non-medical disciplines, including – and here we get back to the Franke Lecture on Economics – economic authorities, planners, politicians, ministers, to study not just the educational system, as Flexner did 100 years ago, but the entire edifice of healthcare in this country. It will take billions and billions of dollars and at least a decade to do this, but I think without it we are lost.
We passed a piece of healthcare legislation that was missing so much, that has gigantic holes in it. We’re not told that Mr. Boehner’s first job is to take it away from us, the little fragment that we have. We need to have a study like this. During all of their studies, and all of their recommendations when they come out, those who are doing the study, and those who are doing the recommending, should be guided by the admonition of the ancient Hippocratic authors to whom medicine was an art, and prognostication was considered one of its most highly valued characteristics.
Medicine now, no less than then, is an art. It’s the art of nurturing the sick back to a state of health, and to realize through that other art of prognostication when it is possible to do so. When it is impossible to do so, we must work to demedicalize the final days, weeks, and even months of life and to nurture the dying, and those who love them, and for us – for we, physicians – for us physicians, actually – to nurture ourselves. The real truth of healing, I propose to you, lies in the nurture.
