19 September 2012

Where Are Today's Philosopher-Physicians?

I recently finished "The Man Who Mistook His Wife for a Hat", by neurologist and popular author Oliver Sacks. It is about the philosophical ramifications of his patients' diseases. 
  • A patient with Korsakoff's Syndrome (severe damage to the memory-forming regions of the brain, due to a vitamin deficiency) lacks the ability to create new explicit memories. Decades after World War II has ended, he does not realize that time has passed beyond the year 1945. He knows himself only as a young man, and has entirely lost his own adult identity. Can someone really "live" if they don't know who they are, and if they have no ability to gain new knowledge or modify their personal narrative and sense of self?
  • One patient with Tourette Syndrome finds that his nervous tics enhance his talent as a session drummer, forming the basis of wild improvisations that bring him musical acclaim. Since it is benefiting the patient, should Tourette Syndrome here be considered a disease? Should the Tourette Syndrome be treated? To what extent does Tourette Syndrome define the patient's personality?
  • Another patient is mentally retarded but displays a remarkable spiritual and poetic wholeness that gives her life substance. Is it fair to consider her mental faculties as diminished? Are our psychological and neurological tests able to capture her strengths? 
  • An elderly patient's new-onset seizure disorder makes her to see vivid flashbacks of her forgotten early childhood, unearthing pleasant memories that had long been buried. During her seizures she can accurately picture her parents, who died when she was age 4, as never before. The memories of her halcyon days of youth put her at ease in her waning days. Her case, among others, suggests that humans have a virtually unlimited faculty for storing memory. We seem to be limited only in our ability to recall those memories, an ability that can be paradoxically enhanced by debilitating diseases.
Sacks discusses these cases as a neurologist, as a historian, and as a student of philosophy. He uses his fascinating patients to try to make sense of the human condition.

Sacks attended medical school in England and graduated in the late 1950s. I wonder, is my medical education engendering scholarly thought in a way that might produce writer-thinkers like Prof. Sacks? The answer is no. There are notable physician-writers of the present day (Atul Gawande, Danielle Ofri, Abraham Verghese, and Siddartha Mukherjee come to mind), but they strike me as an exception to the rule.

Part of the problem is medical education. We learn the mechanisms of disease and of treatment in thorough detail. But there is little discussion of the wider consequences of what we're learning. The humanities are virtually divorced from my medical education. My school spends about 2 hours of lecture on clinical ethics, with no opportunity to receive further instruction. We are not taught about the history of medicine, or of the philosophy of the mind-body problem, or of the mathematical underpinnings of diagnostic medicine. We learn little about the laws, corporations, and political systems that govern the practice of medicine, about other countries' medical systems, about ways to implement population-scale interventions that prevent disease in the first place. There is so much medicine to learn that we are reduced to learning it in a vacuum, isolated from the fascinating scholarly fields that border, affect, and inform medicine. In many respects, medical school feels like trade school, like learning how to repair cars. We are expected to be learners, but not scholars.

Aren't we missing something substantial? Authors, poets, and philosophers have spent millennia grappling with death and illness, understanding how to make sense of the human experience and how to understand our interactions with others and with ourselves. It offers something that science cannot (and I say this as an undergraduate science major): it offers resiliency, insight, and perspective. When our medical education teaches science at the expense of the humanities, doesn't it also untether itself from humanity? Is it wise for our healers to be ignorant in literature and philosophy? Indeed, can those ignorant of literature and philosophy even be healers?

Part of the problem too is the medical admissions process. Getting into medical school demands that one excel at conventionality. Prerequisites are science and math classes, and applicants are strongly encouraged to net publications and shadow physicians. It demands that an applicant check boxes well, and that they be a scientific kind of thinker. Yet the pre-med process boxes out creative and compassionate thinkers that could innovate the field. The medical profession is beginning to recognize this problem, and is retooling the MCAT to emphasize ethics and social sciences. At the end of the day, though, the MCAT is just a multiple-choice test. Multiple-choice tests demand uniformity of thought, which is the exact opposite of creative thought. Fittingly, virtually every exam I've taken as a medical student has been multiple-choice.

The question really comes down to our identity: what do doctors believe a physician should strive to be? I think most doctors would say, a physician works in a medical setting in the care and treatment of patients. Medical school is structured around this particular mission, and it tends to accept those applicants that abide by it.

My view of medicine's aims is more expansive. I believe that physicians should improve the plight of man, using a knowledge of science as well as whatever other tools are available to them. This could be through patient care, through politics, through education, through researchanything. If medical schools were to adopt this far-reaching mission, and to teach students through that lens, medical education would necessarily look dramatically different. I think our country would look dramatically different, too, and for the better.

I'm hardly the first to believe that medicine should broaden its "scope of practice". The field of pathology, a branch of medicine that involves little patient interaction, was partly founded by Rudolf Virchow. Virchow also founded "social medicine," a nearly nonexistent branch of medicine that studies and addresses the societal determinants of disease (like famine, war, and public policy). In his words, "The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction." Though written over 150 years ago, I believe they hold quite true today.