by Robert Coles
anything of you—
not bravery or anger, not even
a good fight.
At death
you become wholly mine.
Your last glance, your last
sensation of touch,
your breath
I inhale, incorporating you
into memory.
Your body
silvery and still on the bed
your lips fluttering into blue.
I pull your hand away from mine.
My other hand lingers, traces
your finger from the knucklebone
to the sheets
into which your body sinks,
my lips over yours,
my cheek near the blue
absence of your breath,
my hands closing
the silver stops of your eyelids.
Jerome Lowenstein
CAN YOU TEACH COMPASSION?
Reflecting on his medical education, the intern in this essay bitterly notes, “I don’t know if you can teach compassion, but you surely can teach the opposite!” Jerome Lowenstein’s eloquent essay answers the question posed by its title in the affirmative, explaining the importance of “a dedicated, self-conscious effort” on the part of medical educators to nurture humanistic qualities that “cannot be achieved by a chance remark on rounds or even by role modeling.”
JEROME LOWENSTEIN is a professor of medicine and co-director of the hypertension and renal disease section at New York University Medical Center. This essay comes from his collection titled The Midnight Meal.
In one of our Humanistic Medicine seminars, the small group of medical students, interns, and residents was challenged to respond to the question, Do you think we can teach you compassion? After an uncomfortably long pause, an intern said in a voice that seemed to convey both anger and shame, “I don’t know if you can teach compassion, but you surely can teach the opposite!” He was referring to a phenomenon that is well known in the development of medical students and house staff. At a minimum, it might be termed “hardening,” a learned insensitivity to the pain and suffering and the needs of patients. At its worst it is seen as a dehumanization of patients who are referred to, in order of decreasing humanity, as “MIs,” “hits,” “crocks,” “gomers,” and “shpozes.” This process, which Robert Jay Lifton has described as “psychic numbing,” occurs with remarkable speed, often within the first one or two years of clinical training. The regularity with which this desensitization occurs challenges the notion, which I have often heard expressed, that one cannot change the behavior and attitudes of young men and women already in their middle twenties.
The question is not whether we can teach compassion but rather whether we will teach compassion or its opposite. I have heard students being taught the opposite of compassion. Some house staff caution naive medical students against “becoming too involved” with certain patients or counsel that “time spent with the books” will get them further than learning more about any single patient. Academic success and recognition seem to go to the stronger and faster. Early in their training, medical students are troubled by the realization that many of the angry and embittered physicians they see as house staff or attending physicians on the hospital wards stood in their places only a few years earlier.
Why are we faced, at this time, with these questions about teaching compassion ? Compassion, empathy, respect for the uniqueness of others are behaviors and values that have always been regarded as the very qualities that lead young men and women to enter the field of medicine. They were never taught, as such, but rather were nurtured and reinforced by prolonged contact with teachers who served as role models, and with patients. As the pace of medicine has accelerated in the second half of the twentieth century, the slow educational process by which physicians “learned compassion” suffered. Physicians today, in their roles as teachers, complain that they feel overburdened by their responsibilities for the care of patients whose illnesses are complex and often require the expertise of teams of specialists. Many physicians are intimidated by the very large body of knowledge they must master and transmit to students and house officers. One way of coping with these very understandable feelings is to narrow one’s focus, to deal with only that part of the disease one knows best and leave the rest to others with different areas of expertise. This does not work well in the care of patients, nor does it make for good teaching or role modeling. To focus on a specific problem, no matter how important or interesting, it is usually necessary to direct attention away from the patient, where all problems intersect.
If it be granted that it is possible and necessary to teach compassion, where is the time and where is the place? My response is a personal and perhaps idiosyncratic one. It requires some explanation. For many years I have taken pride in my ability to teach students and house staff. I try to approach clinical problems from the point of understanding the underlying pathophysiology; I feel that pathophysiology provides a solid underpinning for differential diagnosis, provides a sound direction for treatment, and is instructive for students and house staff. In recent years, on a busy teaching service, I found little time to explore with students or house staff issues related to the lives of patients that were presented to me on daily rounds. Patients’ understanding of their illnesses or their responses rarely found a place in my daily teaching rounds. Was this because I felt these issues were unimportant or unrelated to the care of patients? Certainly not. I felt that I was coping as well as I could with the time pressures of teaching on an active medical service. Looking back on this time, however, I now recognize that another subliminal factor was responsible for my ordering of priorities. I recall that, as a student and house officer, my role models among attending physicians were familiar with all the recent medical literature ; they challenged us to understand complex pathophysiology. The attending physicians whom I and my peers tried to avoid, if any excuse could be found, tended to fill our teaching sessions or rounds with anecdotes and platitudes about patients. I will never be able to accurately reconstruct what they were trying to teach, but I realize now that when I became an attending physician I felt a deep discomfort, during my rounds, whenever I heard myself deviating from the image of one of my rigorous scientific role models.
I was keenly aware that an important element of medical education was not being addressed, by me or by many of my colleagues. I found myself quite comfortable discussing with students and house staff their experiences and responses to patients as well as my own observations, feelings, pleasures, and discomforts in physician-patient interactions in our weekly Humanistic Medicine small-group meetings with medical students and house staff. Yet despite my involvement in the Humanistic Medicine Program, it was rare that I would raise one of these issues on daily morning rounds. I restricted these discussions to our afternoon small-group meetings, although the meetings were with the same group of students and house staff! Two or three years ago, as an experiment, I decided to integrate my “afternoon” style into my morning attending rounds. This was not exactly a planned or deliberate step. I found myself increasingly uncomfortable with the manner in which our students and house staff glossed over critical information in their daily morning case presentations. Patients were described, in a word, as “homeless,” “undomiciled,” “an IVDA,” or “a shooter.” The traditional presentation of the patient’s social history was frequently no more than a recitation of how much the patient smoked and whether the patient used drugs or alcohol and in which form. The most streamlined case presentations boiled this information down to a simple formula, “x pack-years, y bags, and z quarts daily.” I remember vividly the first morning when I interrupted an intern in the middle of his opening sentence, “This is the first hospital admission of this thirty-five-year-old IVDA . . .” I asked, “Would our thinking or care be different if you began your history by telling us that this is a thirty-five-year-old Marine veteran who has been addicted to drugs since he served, with valor, in Vietnam?�
�� There was an embarrassed hush. As I left the ward later that morning, I reflected that the few minutes taken up by my question might have been my most important contribution of the day, possibly more instructive than my comments about pneumocystis pneumonia, arterial oxygen saturation, or respiratory alkalosis. I have continued to insist that patients be “personalized” in case presentations and find that I have been able to integrate details about patients’ perceptions, responses, and needs without sacrificing attention to other aspects of clinical medicine. I am no less rigorous in my analysis of clinical data, nor has my interest in pathophysiology waned. The response of students and house staff reassure me that I have not crossed over to “anecdotes and platitudes.” I have come to believe that the time and place to teach compassion are the time and place in which all of the rest of medicine is taught.
If we are to preserve and nourish humanistic values in medicine, if we are to teach compassion, it would seem to me that the process must begin with a clear recognition that this is the responsibility of the faculty who teach medical students and young physicians. It would be tragic if humanistic medicine were to become “alternative medicine” or a subject—worse yet, an elective subject—in the curriculum. The presentation of courses on the history of medicine and on humanism in literature has provided a forum for emphasizing the importance of the patient’s narrative and for examining characters presented by Thomas Mann, Lev Tolstoy, and Aleksandr Solzhenitsyn, patients described by Oliver Sachs, and the ways in which illness transforms people’s lives. These courses engage ethicists, sociologists, and talented educators from other fields in teaching medicine, but the presentation of such important concepts as “small museum pieces,” to my mind, falls short of the real need in medicine today. If “teaching compassion” is a part of teaching medicine, it should be the responsibility of all those who teach clinical medicine. I am sure that there are faculty who would reject the notion that “teaching compassion” is their responsibility. I would view them in the same way I view a teacher of medicine who rejects the idea of teaching physical diagnosis or pathophysiology. This person might be a gifted and valuable teacher, but this outlook is a distinct limitation. As Hashim Khan, a legendary squash player and teacher, wrote, “I once knew a man who played the piano with gloves. He played well, for a man with gloves on.”
Kirsten Emmott
1852: J. MARION SIMS PERFECTS A REPAIR FOR VESICOVAGINAL FISTULA
A procedure is perfected and quality of life is improved. The inventor is celebrated, but is the victory worth its price? While documenting a period when surgery was a crude art at best, this historically accurate piece challenges readers to see a side of advancement in medicine often ignored. Kirsten Emmott’s poem raises the question of means and ends, and underscores the vital importance of three words in the definition for altruism offered in this anthology: “at all times.”
KIRSTEN EMMOTT is a general practitioner in British Columbia. This poem is from her collection of poetry How Do You Feel? Another poem from her collection, titled “Unwed,” appears later in this anthology.
We’re slaves, the three of us,
useless now to Master since our troubles;
he gave us to Doctor to try to fix us.
When I lay in labor so long,
I cried to the midwife, save my baby,
just one to keep, so many sold away from me—
but baby he died anyway
after being held fast inside so long.
Doctor said his head wore through my passage
into my water passage.
That’s why I drip all day long
out my woman passage—
like a baby, I wear clouts,
I stink, no man want me.
Master say get out the house,
stay in the yard, the field—
Anarcha and Lucy the same,
hurt having Master’s babies,
the babies die and they torn for life.
Our cabin stink of piss, our clouts hang to dry
all over the place.
Doctor cut us so many times,
sew us this way, sew us that way,
but the stitches don’t take.
Three days later the water and blood
drip out together.
We still torn, we still drip.
Doctor cut Anarcha thirteen times and she still drip.
Maybe all this cuttin’ help somebody some day.
I don’t know, I got no say.
He gets four strong field hands
to hold me down, kneeling.
He don’t say nothin’ to me.
I hear him behind me, I hear the knives.
Ain’t no use to scream or fight,
“Shut up, gal,” and a hand over the mouth—
he puts those spoon things in me,
then he cuts me inside—I feel the blood
runnin’ down my legs to the floor—
then he picks up the curved needles—
and it goes on and on
till I pass out.
Fever’s right bad the next day always
but we got to sit up and sew.
We too useless for other work.
We sleep side by side on the cabin floor—
no sense wastin’ straw on us, we’d need
new pallets every day.
We be better off dead, I cry.
Lucy say no, pray to Jesus and we be healed,
but what Jesus ever done for me?
Anarcha say she cry every time Doctor say to her,
get ready, tomorrow.
He got an idea to sew her up with silver wire,
say this time it work for sure.
Jesus, you a man,
you never said woman made for this,
a field to be sowed with wire
over and over until she bears.
Ain’t we done enough bearing?
Jesus?
Robert Jay Lifton
from THE NAZI DOCTORS
This selection exemplifies the horrific antithesis of altruism. Psychiatrist Robert Jay Lifton methodically traces the chilling development of a particular “logic” during the early years of the Third Reich, one that eclipsed “ethical and beneficent medical care” by designating some human beings as “life unworthy of life,” burdens on the state, and “human ballast,” subject to systematic destruction under the watchful eyes of the German medical community and Adolf Hitler himself. The development of “mercy killing” in Nazi Germany serves as indisputable evidence for insistence that physicians be altruistic “at all times.”
Lest the need for such persistent vigilance be questioned, an item in the New York Times dated August 26, 2001, noted that Johns Hopkins University was under federal investigation for its oversight of a “study” using “healthy children to test different methods of lead abatement in cheap inner-city rental housing.” The Times noted that the Maryland Court of Appeals “compared the research to Nazi medical experimentation and the infamous Tuskegee syphilis study.”
“The fact that there could be relatively ordinary doctors who killed,” Lifton notes, “tells us much about the broad susceptibility of unremarkable men to become killers.”
ROBERT JAY LIFTON is Distinguished Professor of Psychiatry and Psychology at John Jay College and the Graduate Center of the City University of New York. He received the National Book Award for his book Death in Life.
Hitler had an intense interest in direct medical killing. His first known expression of intention to eliminate the “incurably ill” was made to Dr. Gerhard Wagner at the Nuremberg Party rally of 1935. Karl Brandt, who overhead that remark, later testified that Hitler thought that the demands and upheavals of war would mute expected religious opposition and enable such a project to be implemented smoothly. Hitler was also said to have stated that a war effort requires a very healthy people, and that the generally diminished sense of the value of human life during war made it “the best time for the elimination of the incurably
ill.” And he was reportedly affected by the burden imposed by the mentally ill not only on relatives and the general population but on the medical profession. In 1936, Wagner held discussions with “a small circle of friends” (specifically, high-ranking officials, some of them doctors) about killing “idiotic children” and “mentally ill” people, and making films in “asylums and idiot homes” to demonstrate the misery of their lives. This theoretical and tactical linking of war to direct medical killing was maintained throughout.1
By 1938, the process had gone much further. Discussions moved beyond high-level political circles; and at a national meeting of leading government psychiatrists and administrators, an SS officer gave a talk in which he stated that “the solution of the problem of the mentally ill becomes easy if one eliminates these people.”2
Toward the end of 1938, the Nazi regime was receiving requests from relatives of newborns or very young infants with severe deformities and brain damage for the granting of a mercy killing.3 These requests had obviously been encouraged, and were channeled directly to the Chancellery—that is, to Hitler’s personal office. Whatever the plans for using war as a cover, the program for killing children was well under way by the time the war began. And from the beginning, this program circumvented ordinary administrative channels and was associated directly with Hitler himself.
The occasion for initiating the actual killing of children, and of the entire “euthanasia” project, was the petition for the “mercy killing” (Gnadentod, really “mercy death”) of an infant named Knauer, born blind, with one leg and part of one arm missing, and apparently an “idiot.” Subsequent recollections varied concerning who had made the petition and the extent of the deformity, as the case quickly became mythologized.b
