The Finest Traditions of My Calling by Abraham Nussbaum
Seeing Wisely...in the Tradition of Hippocrates
“May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” Hippocrates wrote that immortal line in the 5th century BCE. Today, those traditions are not only relevant, they are more critical than ever.
In his book, The Finest Traditions of My Calling: One Physician’s Search for the Renewal of Medicine, writer and physician Abraham Nussbaum discusses how hearkening back to those conventions would not only change the way doctors practice medicine, but could revitalize the healthcare system.
Nussbaum believes the essence of those traditions is a way of being fully attentive to the patient. “Being able to sit with someone and really listen to them,” he says, is the most valuable thing a physician can offer her patient.
But how does that notion fit in today’s healthcare environment? How can it?
With compelling eloquence, Nussbaum reveals the (mostly) good intentions that led to the deeply flawed system that we have today, and writes a thoughtful prescription for what ails it. He points out that few of the healthcare reforms thus far proposed address a fundamental problem. “Physicians no longer see patients as people.”
Throughout the beautifully wrought book, the author makes reference to a moral imperative from Sir William Osler, the father of contemporary medical education: “The value of experience is not in seeing much, but in seeing wisely.”
Quality over quantity in healthcare seems almost a quaint notion, but it is, according to Nussbaum the root of the problem. He writes, for example, that striving for population health is a worthy goal, but valuing public health over individual wellness has put too much emphasis on standardizing outcomes. His point being, focusing on the outcome pulls doctors farther away from their patients when they most need doctoring. The book is full of examples of how focusing on outcomes has negated the value intrinsic in the process of medicine, and the process of healing itself.
Among other luminaries, Nussbaum re-introduces us to Osler, who is credited with creating the medical residency and establishing the ascending roles from medical student to intern to resident to fellow to attending physician. He also was largely responsible for increasing the rigors of medical education after the release of the pivotal Flexner report in 1910, which resulted in the closing of half the nation’s medical schools.
Nussbaum points out that Osler reformed medicine largely by placing pathology at the foundation of clinical medicine, which he says was the beginning of teaching students to see patients differently.
“That’s the proving ground of a physician’s skill and character, even though it teaches us to see the body as a collection of diseased parts,” the author says.
In his book, which is part memoir, part history of medicine, we learn about Osler’s remarkable correspondence with Dr. William Beaumont, a US Army physician who illuminated the process of digestion. But Beaumont made most of his research observations through a glass tube that had been inserted into the stomach wound of a patient. The good doctor, who later became known as the “Father of Gastric Physiology,” hired the fistulous patient as a handyman, and kept him alive through more than 235 experiments.
Osler was a founding faculty member of the Johns Hopkins University Medical School and a physician for whom countless medical school lecture halls are named. But if guilt can be transferred by association, Osler might well share in Beaumont’s unscrupulous work. He was not only a supporter of the research, he sought to keep the stomach and put it on tour for medical students, after the patient’s passing and against the wishes of his family. As Nussbaum puts it, even the great Osler was “obsessed with parts and money.”
Nussbaum shares with us his eye-opening experience as a first-year medical student, when he had to dissect a cadaver. He writes that the goal initially was to see the way the subcutaneous landscape as it looked in anatomy textbooks; to filet the once-living tissue, lay it on a cold metal table, and arrange it prettily.
The chapter not only sets the scene for a discussion of the evolution of medical education; it is also an apt metaphor for today’s healthcare, which Nussbaum refers to as “algorithm medicine.” Cutting away the distinguishing features of a person is analogous to the counting and categorizing that dehumanizes patients today, thus affecting how physicians “see” their patients, and how patients see their doctors.
The author offers a series of antidotes for curing the diseased system we have today. Nussbaum makes note of rules and regulations that have resulted in doctors spending less time with their patients, even though they are seeing more of them; they are literally “seeing more” instead of “seeing wisely.” Auscultation offers a means of listening to patients more deeply; the stethoscope is a familiar tool that not only helps doctors know their patients better, it also helps patients feel truly listened to.
Among other things, Nussbaum notes the strictly monitored duty hours that leave no single doctor in charge of taking care of a patient. Back in 1984, long duty hours were cited as causing the death of a patient, and paved the road to strictly enforced limitations on a resident’s workweek.
On the surface, this rule sounds like a good thing, but Nussbaum makes the argument that this has also diminished the doctor-patient relationship. Prior to the rule, one doctor would look after his or her patient for as long as the healing process took.
In another chapter, the author discusses an over-reliance on checklists in medicine. “As checklists encourage physicians, nurses and other practitioners to focus on common errors, they draw attention away from uncommon errors,” he writes.
So, as a patient is checklisted right out of the ER, for example, her doctors may overlook signs that would enable them to correctly diagnose and treat the real problem.
Interestingly, what Nussbaum believes is the critical first step for fixing health care is not to toss the insurance system or throw out tort law. It’s to be more careful and intentional with language. He believes in the words of George Orwell, who, in his famous essay, “Politics and the English Language,” wrote that inaccurate and foolish language “makes it easier for us to have foolish minds.”
“If we would stop talking about these places as factories,” Nussbaum says, referring to the hospital in which we sit, “if we would stop talking about patients as customers and consumers; if we would stop talking about healthcare practitioners as providers” -- that in itself would go a long way toward effecting real change.
Perhaps these ideas aren’t surprising from a physician like Nussbaum, who studied religion and literature, and earned a master’s degree in the history of medicine. Nor should it be surprising that he became a psychiatrist in an urban hospital, where he can truly “sit with and listen to” his patients, so he can create some wholeness in their scattered lives.
Nussbaum is not concerned with the lost income and prestige that have resulted from health care reforms. “”Physicians have preserved their pay at the expense of our time with patients and I’m not sympathetic to that,” he says.
It is ironic that in this day and age, when victories are won against once-deadly illnesses and promising treatments are found every day, patients are still suffering. They’re not suffering because of individual doctors themselves, but because of human systems that have been defined by misplaced values.
If doctors go back to the basic tenants of medicine, taking time to be with their patients and investing the time that it takes to heal, it will benefit doctors and patients alike. Maybe it will even bring about, as Hippocrates suggested, joy that comes from healing those who seek help, and joy to patients as well.