I was in New York on 9/11 when the planes struck the World Trade Center and the Twin Towers fell. I was Chief of ICU Nephrology at Columbia University’s hospital at the time, and we anticipated that between blood loss and crush injuries there would be many cases of kidney failure needing dialysis, likely in the intensive care units. The day’s elective cases were instantly cancelled as we implemented the Hospital’s disaster plan. And then we waited. But no patients came. Either they had run clear, or they were ground to dust. As this reality began to dawn on us, the other physicians on duty and I felt a vast emptiness.
Upon reflection, this emptiness provides an insight into one of the great paradoxes of medical practice: On the one hand, medicine is a wonderful profession that provides the practitioner with enormous satisfactions; physicians practice into old age, giving up the art only with the greatest reluctance. On the other hand, medicine is a profession intermingled with tragedy. Men and women present with illness and injury, and one might expect that the weight of this suffering would, over time, grind physicians to dust.
But this does not happen, and for the physician, the frequently wrenching demands of clinical practice are redeemed through service. It was the inability to provide that service that left us with only the emptiness of tragedy. So, a lesson: for the physician, the act of service redeems the experience of suffering.
While I was in fellowship training, I would earn extra money to help pay the rent by seeing patients in a walk-in clinic. I saw all sorts of patients, but one in particular stands out. A 42-year-old man presented with stomach upset. He had experienced abdominal pain and loose stools for two days. On exam, he had a low-grade fever, but his pulse and blood pressure were normal, so he was not dehydrated. As I listened to his abdomen, I heard hyperactive bowel sounds, but his abdomen was soft and non-tender, and when I pressed and then withdrew my hand, he didn’t flinch—his abdomen was benign. There was no blood in his stool and all of this was beginning to look like a relatively minor case of gastroenteritis. I could reassure him and send him home, but something didn’t make sense. This was a 42-year-old who surely had had gastroenteritis before in his life, so why did he take a day off from work to come in for an evaluation? Why now? So I asked him, “What is it that you are worried about?” He hesitated, and then blurted out, “CANCER.”
And as we spoke further, I learned that his family history was not as unremarkable as he had initially suggested, and that his father had likely died of stomach cancer when he was this patient’s age. With this shared revelation into the nature and origin of his fear, the patient could suddenly tolerate his minor illness. We see this: what patients need from physicians is very often not a procedure or a medication; in fact, for general medical evaluations, 90% end in reassurance. As physicians, we listen and learn, we reflect and relate, and we get to know our patients, their illnesses, and their fears. So, the spirit of service manifests itself in a most personal and interpersonal collaboration; and through this shared experience, we relieve, or at least diminish, the suffering of our patients.
When I was in high school, I ran on the track team. During my junior year, I seemed to be sick all the time: sore throats, cough, fever. Then strange aches began to appear in my elbows and shoulders. Still I continued to run. At night, I started waking up to find myself drenched. And these night sweats continued for weeks. I continued to run. Then I started getting pounding in my chest, and I felt as if I were about to choke on my heart. Still I kept running. And then the joints that ached began to swell—first my toes, then my ankles, then my knees—a migratory polyarthritis. Finally, not a moment too soon, I stopped running, told my parents, and presented to my general practitioner, who found a heart murmur on physical exam, and marked abnormalities on my electrocardiogram. Needless to say, he could not quite believe my self-neglect.
I had developed a rather florid case of acute rheumatic fever. Not much shorter than I am now, my weight fell to 113 pounds, and although I never doubted that I was going to get through this, my parents were terrified by the prospect that I would not. My GP and my cardiologist were devoted and compassionate, and the story ends well at many levels: the fevers resolve, the arthritis resolves, the pancarditis resolves, I gain 40 pounds, and I go on to run marathons. Also, it was the experience of my physicians’ devoted care that led me to pursue a vocation in medicine. But all no thanks to me—my neglect of my health and minimizing of symptoms bordered on the psychotic. If anyone did not deserve a break, it was I.
Now describing this undeserved happy ending is what your high school English teacher would have called “development by antithesis”—the gentlest way to share the dark truth already known to all: The stories of our patients frequently do not end well, no matter what our patients do, and no matter what we do. In the end, if not now, then later, all pass from this world. All too often the service we provide, this most personal service, will fall short as we come up against the reality of inevitable decline and decay, a reality that makes the most profound demands on the practitioner. So, all too often, the role of the physician is not the procedure or the prescription, and not even reassurance, but consolation and condolence.
The special demands of medical practice on the practitioner were recognized in antiquity. Last week at the New York Metropolitan Museum of Art, Catharine Roehrig, curator of the Egyptian Exhibit, allowed me, in preparation for this address, to examine the Edwin Smith Papyrus, the earliest extant medical treatise. The document dates to the Second Intermediate Period of Ancient Egypt, itself a copy of a document likely dating to 2500-3000 BC—almost 5000 years ago. The papyrus is remarkable for its virtually modern, rational, and scientific approach. It outlines 48 cases and, in each, a condition—generally a case of trauma—is presented. The nature of the trauma—a laceration or broken bone—is laid out. An examination of the injury is described. Diagnosis and prognosis are formulated. The majority of the cases conclude with the instruction to declare, “This is a condition I will treat,” and then a specific treatment is described. A few cases deal with life-threatening conditions with an uncertain outcome and conclude with the instruction to declare, “This is a condition with which I will contend”—perhaps a little less confident, but an imperative to try nonetheless. But most remarkable are 10 cases wherein the physician is directed to withdraw and say, “This is a condition I will not treat.”
In the face of a clearly and unambiguously lethal injury, the physician restrained himself from futile actions—actions that would violate human dignity. This activity—medical practice—was not farming or weaving or pyramid building. Special rules applied. The service that physicians offer, this most personal collaboration, this service so frequently humbled by the prospect of decline and death, is grounded in the service of a human person with special dignity, a dignity that governs the purview of a physician and the scope of a physician’s ethical actions.
2500 years ago, Hippocrates articulated an oath for a profession that was already ancient—as an art thoroughly mature, even if still awaiting the infancy of its science. The Hippocratic Oath is formulated as a divine oath. The first third of the oath is reverently devoted to medical education. Reverence for the practice of medicine reverberates in its amazing declaration to reckon the one who has taught this medical art “equally dear to me as my parents.” The oath then moves to the heart of the matter with a set of restrictions:
I will follow that system of regiment which, according to my ability and judgment, I consider for the benefit of my patients and abstain from whatever is deleterious or mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; in like manner I will not give a woman a pessary to produce abortion. With purity and holiness I will pass my life and practice my art.
The oath concludes with the physician swearing to forego a surgical procedure for which others are better trained, to forego any act of corruption, any act of seduction, or any violation of confidentiality. The obligations specified in this oath follow from a profound respect for the special dignity of the human person.
It is this special respect for human dignity that drives the quest for the professional virtues so important to medicine—compassion, caring, intelligence, diligence—virtues essential for helping patients and families cope with the mysteries and crises of human suffering and death. The vocation of the physician, at its core, is little changed in the millennia since the Oath of Hippocrates was first uttered: to give care to another person to the utmost of one’s abilities, respecting the innate dignity of that person and all the while subordinating one’s personal wants in a gift of self. This gift can be as simple as work performed above and beyond fair compensation, as complex as the creation and use of advanced technology for the good of others, or as great as the hazarding of life itself.
Each morning as I go to my office, I pass the medical student common room, and there on display is a stone tablet bearing the inscription Haec mea ornamenta sunt (“These are my ornaments”—followed by 14 names):
Students of the College of Physicians & Surgeons, Died of Pestilential Disease while Serving in the Public Hospitals. This tablet is erected by the Faculty, that the Memory of these Martyrs of Humanity may not die, and that taught by their Example, the Graduates of the College may never hesitate to Hazard Life in the Performance of Duty.
Fortunately, relatively few physicians are called upon to give their lives, but in an age of HIV, Hepatitis C, and multidrug-resistant tuberculosis, the threats are real, and regardless of your subspecialty, from this day forth you will forever be a most valuable Good Samaritan in moment of need or a first responder in time of crisis.
Walker Percy, the physician-philosopher, tells a telling tale: One morning a man looks at a newspaper, turns to the horoscope page, glances down, and begins to read: “You are the model of decisiveness. You analyze problems crisply. You come to terms with complex situations rapidly. Your gut decisions are unerringly true.” He pulls up from the page and says, “That’s me! That’s definitely me.” Then he pauses and glances back down, only to realize he’s looked at the wrong sign. He now finds his true sign, and he reads, “You are the model of circumspection. You analyze problems with the greatest care. You weigh all the options. You see the risks and the benefits, the rewards and the opportunities. And when you finally decide, your decisions are true.” He pulls up from the page once more, and says, “That’s me! That’s definitely me.” That night, he unpacks a telescope he had purchased the day before. Quickly he assembles it, and points it to the heavens toward a disc that he sees. This disc does not twinkle, and as he focuses on it, he sees four little dots distributed in a line on either side of the disc. He says to himself, “Does not twinkle, must be a planet. A planet with four moons—it must be Jupiter.” And he is right.
Now Percy asks: How can a man recognize a planet 400 million miles away that he has never seen before, and yet not recognize himself? We cannot recognize ourselves. The graduates cannot recognize themselves. We know ourselves only in relation to others. That is why you have family and friends. That is why some of those family and friends are here today—to tell you and to remind you who you are. So our purpose today is not merely to celebrate a completion. It is not merely to inaugurate a beginning. It is to tell you who you are. I recognize you as persons who have pledged to a life of service, a service that redeems the experience of suffering, a most personal service, a most difficult service with special gravity that follows from its intimacy with the human condition. A special gravity flows from the intrinsic dignity of every human life, dignity that calls forth from you the most profound “gift of self.” Our purpose today is to recognize you as you dedicate your life. Today, I recognize you as doctors.