Retirement is a time of reflection. Most of one’s agency lies in the past. I must organize opportunities to transfer bits of experience, insight and wisdom to those who still do the work if I am to have the joy of continuing to contribute to the dream of a future where we enjoy
…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
I ponder the moments, places and people that molded my sense of professionalism. The faculty at Harvard Medical School in the late sixties gave me more than a foundational knowledge of anatomy and biochemistry, and more than a sense of the traditional decorum between doctor and patient. When Dean Robert Ebert addressed my class on the first day of medical school he gave us his preview of the challenges that would evolve for our generation of practitioners. I don’t have a recording of those words, but I do know what he said about the future of healthcare in a speech at Simmons College five weeks later. In that lecture he focused on the training of physicians who understood the challenges of the populations of the rural and urban poor. The lecture fleshed out much of what he meant when he said:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
Fifty years ago Dean Ebert believed that we were embarking on a journey of many generations searching for the elusive solutions to the complexity of healthcare that our president recently realized in his own epiphany. Doctor Ebert argued that medical educators needed to foster a new professionalism built on the realization that the care of the patient was done best when there was an appreciation of the population or community from which the patient came. He envisioned training a generation of “socially conscious” physicians.
Before my classmates and I had our own experiences with patients at the bedside or in a clinic exam room, we had gathered in amphitheaters to watch our professors interacting with patients in the Saturday morning “clinics.” These Saturday morning exercises were the highlight of my week.
The other activity that was a glimpse of what would eventually come to us in the third year was the chance to “go on rounds” with one of the professors. I was delighted to tag along behind the famous cariologist, Dr. Lewis Dexter as he moved from patient to patient on the wards of the Brigham. We followed our guide like ducklings behind their mother as he or she went from bedside to bedside interacting with patients about their specific issues and concerns. Up close and in real time while real work was being done, we were interlopers on the dramatic interpersonal relationship that involves the trusting reciprocal interaction that forms the basis of a therapeutic alliance.
The medical school had distilled the essence of how to take a history and effectively communicate with the patient in a little pamphlet that was called the “Little Red Book.” The mindset of how to “be with the patient” in an effective therapeutic relationship was the essence of the little “Grey Book” which was a pocket sized copy of Dr. Francis Peabody’s ( Dr. Peabody is pictured in the header) famous lecture/essay delivered in 1926 and published in 1927, “The Care of the Patient.” The last three sentences of the monograph sum up his philosophy and are the cornerstone or entryway to all discussions of medical professionalism as I believe it must be experienced in these times.
The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
Updating that statement from ninety years ago there are many things to consider. On the technical end clinicians struggle with the challenge of managing electronic medical records, oceans of information in multiplying databases, and an explosion of medical science and technology. “Knowing the patient through and through” has new meaning as does “bought dearly.” These days both doctors and patients bemoan the loss of time spent together that is a reality of expanding care to larger numbers while trying to use antiquated concepts of finance and old systems of care. Dr. Ebert told us that we would need to work at organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
What is as true now as it was ninety years ago is that “the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”
Medical students easily absorb the lessons of the Little Red Book. Dr. Peabody’s lessons in the little Grey Book take much longer to understand, as Joseph Ladapo explained in an essay written when he was a third year resident at the Beth Israel Deaconess Medical Center in 2010.
Harvard Medical School did a fantastic job emphasizing the intangible aspects of medicine in our patient–doctor courses, but the focus of our education fell resoundingly on anatomy, physiology and pathology. Further, the fact that we were students and not yet doctors made Dr. Francis Peabody’s storied 1927 essay, “The Care of the Patient,” seem more like words on a page than a living reality…Only during the second year of residency did we finally have enough free mental space to reflect deeply on our experiences.
I am continually amazed by the way in which ideas can come together in a series of interactions over just a few days. My recent ruminations on professionalism have been part of my internal reaction to the complexity and acceleration of the “repeal and replace” debate as I try to see what practice and the experience of receiving care will be like in the new world of Trump-influenced care. I hope that our residual professionalism will be a sustaining source of strength and insight as we grapple with the reality of how to deliver care to the people in those populations that will realize a loss of resources and access. I never expected to find solace and insight in the words of a “rock star.”
As fate would have it I have been enjoying Bruce Springsteen’s autobiography, Born to Run. I had heard him interviewed about his book on Stephen Colbert’s show last September. Springsteen wrote the book without a ghost writer, and he recorded the audiobook. As I was walking last weekend and thinking about professionalism, I was listening to Bruce read his book. Suddenly, Bruce chimed in with his insight on professionalism.
…We are a philosophy, a collective, with a professional code of honor. It is based on the principle that we bring our best, everything we have, on this night, to remind you of everything you have, your best. That it’s a privilege to exchange smiles, soul and heart directly with the people in front of you. That it’s an honor and great fun to join in concert with those whom you’ve invested so much of yourself in and they in you, your fans, the stars above, this moment, and apply your trade humbly (or not so!) as a piece of a long, spirited chain you’re thankful to be a small link in.
Bruce Springsteen, Born to Run, Page 217
I was stopped in my tracks as I kept playing the words over and over again. It is a privilege…exchange soul and heart with people in front of you…apply your trade humbly…a long spirited chain you’re thankful to be a small link in…
I went home and pulled a book of my self that has been there for more than a dozen years. It was Robert Coles’ book from 2003, Bruce Springsteen’s America: The People Listening, A Poet Singing. In the book Coles talks about his personal experiences with physician author Walter Percy and physician poet William Carlos Williams, and places Springsteen in a lineage that includes Walt Whitman and William Carlos Williams as a poet of American place, people and time. His art poetically express all the confusion and pain that describe the blue collar experience and sense of loss that we read now in JD Vance’s Hillbilly Elegy. His songs offer insights that exceed the academic explanations for why the legion of white blue collar Americans with lost hopes in an America that failed them have looked to Donald Trump to shake things up.
After my epiphany on the road with Springsteen, I had another encounter that reinforced my idea that our professionalism needs to be at the core of how we see ourselves in service to our patients in these times of challenge for us all. I have enjoyed volunteering on Monday afternoons in an after school program for fourth, fifth and sixth graders in Newport, New Hampshire. Newport is about ten miles from my home. In those ten miles you travel from lakeside homes with seven digit prices to a post industrial community with all the woes of a town with empty factories, decaying storefronts and shabby homes along neglected streets. It is another world. Hillary won in my town. Donald won in Newport.
Between activities with the children I was in conversation with one of my co volunteers. I discovered that we had one degree of separation. He and his wife had lived in Brookline for many years and they had gotten their care from Dr. Phil Wade at the Cambridge offices of Harvard Vanguard/Atrius. My new friend bubbled on and on about the great care they had received from Dr. Wade. I heard the word professionalism several times as he sought to find ways to expand his gratitude for Dr. Wade. We both knew that Dr. Wade had died much too soon in 2013, but we were certain that the echo of his commitment will linger in the lives of those he touched way into the future.
I hope that we will explore as professionals all that we can do as individuals and together seek to move our system of care toward the ideal that delivers
…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time…in settings that support caregiver wellness.
I hope that more and more professionals will try to collectively advocate for a better future and not just sit and wait to see how this moment works out. We do know the issues. Dr Price and Dr. Verma are not the only physicians who have ideas to present that should be heard and considered.
Away from Washington, where we live and work, we can direct more attention to the one thing we do control more than we wish to admit, which is the cost of care. We must be the ones who say that there is waste that can be removed that adds to the growing cost of care. We can recognize and educate others that there are social determinants of health that must be addressed in the communities where we live and practice. We need to accept the challenge to understand the 2017 realities of the truth of 1927:
…One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
