Only a quarter of what you need to be a great physician is evidence-based. The rest is a matter of the heart.
Have you ever noticed that the more intellectual a person is, the more unhappy they seem? I’ve spent a fair amount of time drinking (heavily) with university types, and I think I’ve solved the riddle. These spoiled PhDs – many of whom have never held a real job – have decided to do away with telos – the philosophical pursuit of meaning. They declare that telos doesn’t exist at all. Worse still, they see this as an assertion of science. Well, I’m here to say that it is not a scientific statement to say that there is no meaning to anything. It is a metaphysical assertion – of no small faith – and in my opinion it is wrong.
Taken to its logical conclusion this denial of telos means that nothing I do has any meaning. Holding a child who is in pain, taking an extra minute to speak to grandma – none of that makes sense in this reality.
How did we get here? What happened to the post-war halls of education where literary criticism had a central place in our being? When did we become slaves to objects with no understanding of ideas? The liberty of the spirit that comes through humility and discipline, if not gone, are certainly vanishing. The positivism of Radio Days and Brighton Beach Memories seem like a land of dreams. The perverted Baconian distinctions of the humanities from science that is the root of the modern university has abandoned the soul.
The problem has seeped beyond the hallowed university halls to our own house of medicine. The Hippocratic Oath to Apollo has been reduced and continues to be reduced to the secular AMA principles of medical ethics, which I am certain will be reduced again when we find a powerful enough moral microscope. The virtue of compassion to human suffering will never be amenable to a differential equation. Knowing you have made a meaningful connection is seen in the eyes of both the doctor and the patient and not in the lab results or in the X-rays. We have signed on to a worldview that will destroy the culture, as science plows ahead without any moral guidance.
But we can do better. I believe physicians can bring more to the medical table than just shifting science, which changes day by day. We do more than just apply equations. We provide comfort and intellectual solace, which is sought by so many and given by so few of us.
Woody Allen (who despite the Soon-Yi thing, is one of my mentors, if not heroes) once declared: “Mankind faces a crossroad. One path leads to despair and utter hopelessness; the other to total extinction. Let us pray we have the wisdom to choose correctly.” Such jokes belie the fact that Allen’s films sit on the edge of the abyss but never slide into the abyss because of a loyalty of the characters to each other. This is the idea of hope. In the last line of Manhattan, Tracy tells Isaac: “You have to have a little faith in people.” Allen understands faith, even without firm definition; which makes possible a sense of inner well-being that reason alone [our science]cannot achieve. Fame at any level, wealth, living in a great city is all meaningless if we live and die alone. A human without love and a community may not be human at all.
I spent my career taking care of patients in the Midwest. These are average Americans – not the meritocratic global elite. They want simple things out of physicians, like reassurance that our scientific view is aware of their suffering and able to relieve their pain as they move through “flammatia moenia mundi” — the flaming ramparts of this world to the next.
Even if you don’t believe in an assimilation of the soul, know that many of your patients do. Don’t believe for one second that you don’t need to minister to this part of their being. Patients have needs and we need to answer those needs, whether we believe in them or not. Today’s intellectuals use big words to show both arrogance and animosity. The Harvard Divinity School – a contradiction in terms? – has become a place where people with more degrees than understanding can analyze the primitive beliefs found in those lower primates who live between the coasts and still practice such rituals. These folks, our patients, are for the most part hard-working Americans who played no part in the economic policies that helped gut America’s manufacturing heartland. If you can’t leave my people anything else, at least leave them their dignity of belief that has for so long kept them together.
If you have trouble with belief in the soul, at least have faith in human relationship, in family and community. Woody Allen is an unabashed admirer of Martin Berber and his I And Thou, which is built on the axiom that it is not good for man to be alone. Individualism and isolationism should never be confused with each other. Allen scrapes the bottom of the Borsht Belt barrel to show us the beating hearts and hope that can relieve the thoughts of our suffering. Who else could have made films in which there was a one-legged tap dancer, a blind xylophonist, and a team of piano-playing birds? And who could have thought up the line: “Thou shalt live in the house of the Lord for six months with an option to buy”? Incredible. Clearly, being a normal mind is way overrated. But make no mistake, Allen is both the product of and the prisoner of a conservative Jewish upbringing in which family was everything. Where have we gone with this proposition? Our science cannot save us.
This brings me back to emergency medicine, and the four things that emergency physicians need for success. First, you must possess the core knowledge and skills of emergency medicine and, more importantly, the knowledge of when to use them and when they are not of value.
Second, you must have the desire to show up and bring your A game. Forgive me for using such words, but you have to care. And you have to convey that you care to the team, showing them that it is your desire to relieve pain and bring solace for suffering. Holding the patient’s hand is not an add-on. It is integral to participating in the treatment process. So much time and effort is given these days to discussing the trendy term “shared decision-making.” The best doctors have always done this. What about when there is no time, you ask? How do we show that we care when an 18-year-old is brought in by the paramedics from a motorcycle wreck and his consciousness is declining? It is precisely in these moments, when families are in crisis and they look to you for help, that you need to see beyond the dispassionate review of statistical data about subdural and epidural hematomas. The question becomes: what would you want done for you and your family? Do that and you will always be right.
Thirdly, practicing emergency personnel need to be calm in the extreme. Remember that the three sempers of the Roman soldiers – semper idem, semper paratus, semper fidalis – begin with semper idem, the call to be always under control, even-keeled. No matter what you see, no matter what is said and what names you were called, stay in control. Losing one’s temper, makes you lose sight of the goal which is always to resolve the problem in the best interest of the patient. Very few situations end well when everyone’s angry. To the young, if you haven’t been there, you will. To the old, if you haven’t been there, I don’t know what you’ve been doing.
Fourth and lastly, a sense of humor is an absolute requirement. We can’t always explain humor except to say it depends on quality and timing. Each one of us has told a story and thought it was going to be greeted with uncontrollable jocularity only to have it fall flat as whale poop. Why? It’s how we view a certain situation at a certain moment in time. The stories we hear and the things we see are so absurd sometimes that you can’t help but enjoy the moment because there’s nothing else you can do. Sometimes we laugh because it’s the only alternative we have to crying. And we laugh because it’s part of being human. IBM’s Watson would never understand the humor in Abbott and Costello’s “Who’s On First,” which may be the best comedy routine ever written.
So let’s review: Of the four things needed every day in the emergency department, only the first – knowledge and technical skill – is evidence-based. Everything else is from the only place which we cannot measure: the soul. Which is no higher than the sky is high, no wider than the heart is wide.
I have always thought that Charles Darwin’s writings on the evolution of his own thinking, as expressed in his opus, The Descent Of Man, are the saddest words ever written. He expressed wonder, when as a young man he wandered the Brazilian rain forest, which inspired in him a conviction that there is more to man than the mere breadth of his body. “But now,” he concluded, “the grandest scenes would not cause any such convictions and feelings to rise in my mind.” Darwin had lost the magic of the unknown, the smallness of humans and the magnificence of the world. How terribly sad.
Darwin went on to fret that civilized society undermines natural selection by caring for the poor, saving the sick and vaccinating people against smallpox; which he felt was a useful disease to cull the weak from the human herd. Darwin need not apply for an opening in my emergency department, unless of course he is willing to work straight midnights.