JC: Well, it’s great to see you, Alan, and thank you for agreeing to this interview. It’s been a long time since I saw you in person. I remember when we first met in 1992 at the Society of Teachers of Family Medicine meeting in San Diego. It was at a poetry reading, and we were both presenting our work there.

I’d like to begin by quoting an article that I saw in the Amherst student magazine from 2008. You had just received an honorary doctorate of science there. It goes like this, “AB’s combination of his education, his love of art, his passion for medicine and his wonderful sense of humor have made him a great warrior in the fight against smoking. Dr SmokeBuster offers an alternate view in the seemingly strict discipline of medicine. He embodies the philosophy of the liberal arts, using a variety of disciplines to communicate his message. Most importantly, AB brings poetry and artistic splendor to the often overly calculated role of science.”

I think that really describes your ability to merge your love of the arts and humanities with humor and your passion for medicine, as well as your public health activism and your career-long campaign against cigarette smoking. So how do you look at that? How do you view those interdigitating components?

AB: First of all, this is so unbelievable. If you told me that when I was struggling to figure out what to do in life, that I’d be interviewed by Jack Coulehan, I’m just really appreciative that you would take the time to do this.

I had great fortune in my upbringing and growing up on the periphery of New York City.

It was really a marvelous time. I thought New York City was where moms took their kids to go to see plays and museums on weekends. I didn’t realize people actually live there. Where I was born, at Rockaway Beach Hospital in New York, you could see the ocean from the hospital. My father, Leon Blum, MD, was an intern there and then a member of the medical staff. He was a general practitioner for 37 years in the very town in which he’d been raised, Rockaway Beach. And that’s where Jonas Salk spent his summers. And Burrill Crohn was from there, of Crohn’s disease fame. So it has a rich heritage. I grew up in a low middle income community, nearby Far Rockaway, where my father, Leon Blum, MD, knew everybody.

My dad was very literary. He would do the Sunday New York Times crossword puzzle, which I could never do. And I had great opportunities to experience culture. Of course, I thought museums were mostly about dinosaurs. I never realized that there were art museums. That was the awakening I got when I went to my first National Conference of Family Practice Residents meeting in Kansas City.

It was pretty boring. So I started walking around Alameda Plaza, and I came across this beautiful building that looked like a Greek temple, and it turned out to be the Nelson Gallery. And that was really my awakening in art.

JC: And you also had an early commitment to activism. It’s remarkable that even as a resident in the late 1970s at the University of Miami, you had already begun, kind of this dual career as a regular practicing physician and as a family practice resident, you organized a campaign against smoking and other unhealthy habits among adolescents. What was the origin of the idea for the Doctors Ought to Care movement?

AB: I think everything I’ve ever done is irony and humor, and even the title of my undergraduate thesis on Robert Frost was called “The Way of Understanding is Partly Mirth” (from a line of one of his poems). I don’t think I would have been able to get through being fired a couple of times, not getting into this or that school, not getting this or that job, missing the deadlines for exams that I had to take, and so forth had I not had a sense of humor.

I was about a 7-year-old watching Brooklyn Dodgers games on TV with my father in the afternoons when he would rest after his 9 am-to-noon and 1 pm-to-4 pm clinic before his after-dinner office hours in our house, where the living room became the waiting room. We loved the Dodgers, and one day he said, “Look at that Lucky Strike commercial. Why don’t you take out our tape recorder and record it, because one day nobody’s going to believe that they would associate sports and cigarettes.” And sure enough, it only got worse as the decades went by. Meanwhile, I had begun an interest in smoking because my father had had a heart attack in his 40s, when I was 5 years old. He started smoking Chesterfields as a medical student and continued through his service in the Army in World War II in New Guinea. It just stuck with me that when and if I ever got to medical school, I’d learn a lot more about that. I never did. Only about 30 minutes of education at Emory was devoted to smoking, and it was a part of a lecture on lung diseases by Dr Brigitte Nahmias. She juxtaposed ads for cigarettes next to pictures of her patients with occupational lung disease and some who smoked. I thought that was a good way to demonstrate the contrast between the macho men in the cigarette ads and the wrecks that she cared for. So with the help of a pathology professor at Emory, I decided to create my own slide presentation of all the smoking-related diseases. By the time I was in my residency, I began speaking in elementary, middle schools, and high schools to try to talk to kids about not taking up smoking and other killer lifestyles that were being promoted to them in the mass media.

At a meeting of the National Conference of Family Practice Residents in Kansas City in 1977, I tried to share this work with the other attendees but was initially rebuffed. I was finally given a room after the main proceedings ended. It was filled to overflowing. Over 50 people came, and one of them was Rick Richards from South Carolina, who told me “You know, I’m going to go back to Spartanburg and do the same thing you do, and I’ll see you next year.” Well, by that next year, we’d organized several chapters, and we were asked to give the main talk at the conference. So DOC, or Doctors Ought to Care, became known for not just lecturing on the dangers of smoking, but also for ridiculing, satirizing and parodying cigarette advertising and the way in which the tobacco companies were getting away with murder. We were the first and only physician organization to confront the tobacco industry itself, and not just angrily, but using humor and MAD Magazine-style satire such as the Barfboro Man and the Emphysema Slims tennis team. These were some of the things that we created when the American Cancer Society was saying, “Oh no, no, you can’t do that. You’re going to get sued.” Well, we were sued, and that only brought more attention to us. We did a t-shirt parody of Miller Lite Beer, whose original slogan was, “Miller Lite. We’re having a party.” Our slogan had a guy with his arm around a toilet saying, “Killer Lite. I’m grabbing a potty.” Miller Brewing, which was owned by Philip Morris at the time, sued us in state and federal court. We won the case, but it was no fun being involved in litigation with the world’s largest cigarette company.

JC: That makes me want to jump ahead to some of the exhibitions in the Center for the Study of Tobacco and Society. I was reviewing the website last week and the whole thing is so impressive, but the humor and the irony in the titles and the text of some of your exhibitions is amazing.

So to get into that, let’s move to the beginning. I believe it was 1997 when you began the Institute for the Study of Tobacco and Society at the University of Alabama, let’s go back to Doctor Ought to Care.

Alan: DOC was started in 1977. I was in internal medicine after my graduation from Emory, and I loved my internship at McGill’s Royal Victoria Hospital in Montreal, but I kept on running into family practice residents at Montreal Jewish Hospital who seemed to be loving their experiences even more than I was. So when I was on vacation in Miami, I thought why not look up family medicine?

I walked into the Department of Family Medicine at Jackson Memorial Hospital of the University of Miami, and there was Irwin Redlener, who was actually a pediatrician. Irwin was filling in at the request of the chairman Lynn Carmichael. It turns out that this was the first family medicine residency in the United States. Lynn also helped found the Society of Teachers of Family Medicine and became the first editor of its journal Family Medicine. The residency had features found in few other training programs of that era such as sports medicine, podiatry, integrative medicine, pastoral care, an annual symposium on sexuality, extensive community outreach, a resident-run evening clinic, and a monthly book group to discuss The Person: His and Her Development Through the Life Cycle by Theodore Lidz. It was just amazing timing for me, and I never looked back.

Lynn tolerated me pretty well for my activism on tobacco after initially chastising me for trying to convince his secretary to stop smoking. He eventually admired what I was trying to do, which was to bring our knowledge about health into the community to try to make up for the health and socioeconomic disparities in the neighborhoods around the inner-city hospital.

Dr. Richards and I were soon joined by another family physician, Dr. Tom Houston, and through the National Conference of Family Medicine Residents we were able to disseminate our activist approach to tackling the killer habits. In the 1980s we wound up having close to 100 chapters of

DOC in medical schools and family medicine residency programs, some of which still exist. Our approach was to use humor and satire, as opposed to all the staid organizations like the American Cancer Society, the American Heart Association, and the American Lung Association, which still relied on pamphlets, posters, and unpaid public service ads on TV that usually aired at 3 in the morning. DOC was the first health group to purchase counter-advertising space on billboards, bus benches, TV, and radio. No one else had ever done that. We were also the first to involve teenagers in our work and to tap the highest level of creativity and commitment of every family physician we could find. In 1978, I co-hosted a conference with a junior high school student that was attended by 150 students from 30 schools in South Florida to train them to help raise the awareness of their peers about the targeting of young people by the purveyors of cigarettes, alcohol, and junk food.

Flash forward to 1997 when I was on the faculty at Baylor College of Medicine. I was invited to give the family medicine residency graduation address at Tuscaloosa. I shared my sketches and stories of patients and also gave a grand rounds on the physician’s role in ending the tobacco pandemic.

Afterwards, the chairman, Jerry McKnight, asked me if I wanted to stick around. I thought he meant going for a beer, but he wanted me to apply for a new endowed chair position in family medicine.

When I moved to Alabama two years later, I started the Center for the Study of Tobacco and Society. DOC was still going, but I also wanted to do something different such as researching the history of smoking and efforts to counteract it.

I began to organize the vast amount of material that I had amassed over the years through what I called a daily biopsy of the smoking pandemic – the largest collection on the tobacco industry, cigarette marketing, and anti-smoking advocacy at any university. This was all pre-internet and pre-ebay. I had tens of thousands of items, and the University of Alabama was kind enough to provide some space. I thought of this as both a museum and an archive, and for the next 15 years I hired graduate students from the School of Library and Information Studies to start cataloguing the collection.

The main work product of the Center is exhibitions. We began with an exhibition at the annual convention of the Association of American Editorial Cartoonists called “Cartoonists Take Up Smoking!” It took ten years to research and involved acquiring over 300 original artworks from the nation’s newspaper editorial cartoonists. The exhibition then went to the National Museum of Health and Medicine in Washington for a year and traveled to ten other venues. So we had a great opportunity to share our work, but then it dawned on me in 2015 to do online exhibitions to reach a much larger audience. We’ve now done nearly 40 exhibitions, and I’ve never looked back.

JC: And I think that that those online exhibitions, each of them, seems to be a massive enterprise with so much richness in the visual material, in your text, comments and so forth. It’s remarkable that you have been able to collect this much essentially social history and curate it in such innovative ways.

Alan: Well, here comes the trigger warning, because I do this mostly for me, partly because. I don’t think most people understand the smoking issue. I really don’t. I don’t think there’s much to cheer about, in spite of the progress that we’ve made in reducing adult smoking from over 40% in 1964 to less than 15% today. Just this year, an investigative report was released about how low-tar cigarettes are bigger than ever in China, because they’re still pushing the absurdly fraudulent notion that there can be a safer cigarette. Even the Journal of the American Medical Association bought into this for awhile back in the 1970s. It’s such a tragic history in this country that I cringe whenever I hear public health people saying that the reduction in cigarette smoking is the greatest public health triumph of the 20th century. Not at all. In my opinion, it’s just the opposite. 

We learned everything we needed to know about smoking by 1964 when the Surgeon General’s report came out. My dad taught me everything I think I needed to know when I was much younger than that. I wrote my first article on smoking when I was editor of my high school newspaper, The Woodmere Academy ECHO. And I think I’m the longest running individual on this issue, because I’ve been doing this with a passion for over 60 years – – fortunately, I haven’t had to earn my living from my anti-smoking work. And that’s where my trigger warning comes in, because it’s hard to imagine how thoroughly the field has been professionalized. You have to have a Master of Public Health or a Doctor of Public Health degree to get a job in it, as compared to the hundreds of grassroots activists from all walks of life across the country who led the way for decades in passing local clean indoor air laws. And guess what it’s called now: “Tobacco Control.” Of course, it’s not about controlling tobacco. It’s about curbing smoking and its promotion. This issue is something that medicine hadn’t addressed before, because unlike an infectious disease it’s a human behavior that’s taught to us by an industry that’s making an enormous profit. So I believe my contribution was to shift the focus away from lung cancer and smokers and instead onto Marlboro and the people in the tobacco industry who promote it. I think that was an exponential leap from where we were before then.

There were quite a few health care professionals who were opposed to smoking. Thoracic surgeons Alton Ochsner and Michael DeBakey were warning that cigarette smoking caused lung cancer beginning in the late-1930s. For their trouble, they were ridiculed by the medical profession. Organized medicine didn’t want anything to do with fighting smoking. (For one thing, their medical journals accepted lucrative cigarette advertising revenue until well into the 1950s; for another, two-thirds of physicians in the 1940s smoked.) So what I think we did in DOC was to shift the focus to monitoring the tactics of the tobacco industry. Our strategy gave permission for everybody else to point the finger at the industry as the source of the problem. But the federal government never devoted any funding to fight smoking, and there was relatively little effort. So leading the way was that band of people who hated going into restaurants or getting on airplanes and breathing tobacco smoke. It was that activist group of people– – not the public health people, not the physicians – – who started the nonsmokers’ rights movement. And then there was a guy like me who was looking at the advertising and promotion of tobacco products. But most of those working in this field today are focused on regulation and legislation, even in this non-legislative era. Then there are the full-time smoking cessation researchers, who are practically studying nicotine receptors on toenails rather than looking at the larger picture. They’ve medicalized and “pharmacologicalized” smoking cessation. As a result, physicians no longer take an extra minute or so to encourage their patients to stop smoking. They just prescribe a drug. And I don’t think that most people in tobacco control are looking at the fact that we could have done so much more in these 60 years. For example, the first time the government ever spent a penny on paid advertising to fight smoking was in 2012.

In 1998, the state attorneys general forged a $206 billion settlement with the tobacco industry which sounded great. But although most of that money was supposed to go to fight smoking, only 2% of that has been allocated by state legislatures for tobacco use prevention and cessation. It’s all about the money.

JC: It’s all about the money.

Alan: An internist colleague, Ed Anselm, made this marvelous comment, “The most addictive thing about tobacco is money.” And he wasn’t just talking about the tobacco industry, but also about the people who say they’re fighting smoking but are really just fighting over the grants to write policy papers telling legislators what to do about smoking.

It’s a dark field.

JC: It sounds, from what you’re saying, you know, the image I have is Socrates, as a gadfly in Athens talking about the gods and so forth, and his questions threatening the status quo. One thing has improved though, you haven’t been convicted. You haven’t had to take the hemlock.

Alan: No, I was arrested, though. I’ve been arrested a couple of times for demonstrating (but never charged), once with a city councilman in Houston when we went to the Astrodome to protest a Cinco de Mayo festival sponsored by RJ Reynolds’ Camel cigarettes. Let me just give you an example of the absurdities I’ve experienced: I was fired as editor of the New York State Journal of Medicine after three years, having produced the first theme issues on smoking at any medical journal, and which brought national attention to the Journal. As editor, I had to attend the monthly board meetings of the of the Medical Society of the State of New York (MSSNY), which published the Journal. To paraphrase the Borscht Belt comedian Henny Youngman, the average age of the board members was deceased. I was about 20 years younger than the next youngest person in the room, and all they were talking about were economic matters like the high cost of malpractice insurance. It was not at all about health and medicine and helping people, in my opinion. But I’m grateful to MSSNY for having had the opportunity to do these theme issues on tobacco problems. Following the second one, though, I was fired for having spent too much time on smoking.

JC: I think we can agree that that money talks, and we lived in the mid-20th century in a culture in which smoking was not only acceptable, but it was really highly touted. For example, most doctors smoked Camels, but on the other hand, don’t you feel that that your campaigning, and your creativity has contributed to cultural change, even though it’s been at a slow pace?

Alan: I did a teaching fellowship in family medicine at the University of Miami after graduating from the residency program. And what I learned was how to give a good presentation and how to write learning objectives. These skills may seem simple, but that’s deceptive. First, there is the cognitive objective (imparting information), which 99% of lecturers think is the entire lesson they are supposed to teach. Then there’s the behavioral objective, which can teach learners how to do a procedure or demonstrate a skill. But what they’re missing, I think, is the attitudinal objective. I came away from that fellowship understanding that every presentation, every paper, every research poster I would ever do would have the reader, viewer, or the listener going away saying, “Gee, I never thought about it like that before.” That’s an attitudinal objective. I wanted to change the way people looked at an issue.

It’s something that stays with me every time I advise a resident on giving a presentation. I also do this in my exhibitions on tobacco in the hope that the viewer can see the ironies and learn the lessons from decades of foot-dragging by organized medicine, the public health community, and academia – and their fear of confronting the tobacco industry – that can be applied to tackling other challenging health problems such as gun violence, obesity, emerging and re-emerging viral diseases, and digital media addiction. There are many ways we can look at the smoking issue. Our failure to address it for so many decades is a metaphor for how we’re dealing with the wired epidemic of kids having the attention span of a fig.

JC: In 1964 when the Surgeon General came out with his first report, I believe 45% of adults in the US smoked, and now it’s approximately 11%, and the images that you have in your in your exhibitions show how trendy and culturally appropriate smoking was at that time. Now, you have to admit that there is a significant cultural awareness that smoking isn’t the thing to do, and that at least if you do smoke, you have to go out to the back, and you can’t smoke here or there, and there’s a certain kind of negativity against it. I consider that a cultural change. And of course, all of the tobacco corporations have had the time over those 60 years or so, to adapt to these new conditions and to spread their tentacles elsewhere. But it seems to me, it does constitute a change.

Alan: Jack, we look at our time now as an age of disinformation and regression, and dare I say, the word “retribution,” because we have willful ignorance that I haven’t seen in my lifetime. I lined up at my school in Woodmere, Long Island, to get my polio vaccine as a five-year-old. I was in the original Polio Pioneer trials. We have people today who are saying they’re “doing their own research” as to why they won’t get a Covid vaccination that has saved millions of lives even though these vaccines were developed in record time, thanks to our knowledge of previous epidemics, especially SARS in the early 2000s. Most of the time developing the vaccine for Covid was taken up with the trial, not with the development of the vaccine.

I think the missing element today in countering this horror is humor, and that’s why I like to think that MAD Magazine was my leading medical journal for many decades. I actually got to meet the editors and the publishers of MAD because I wrote a letter to publisher Bill Gaines and editor Al Feldstein when I was editor of the New York State Journal of Medicine. I asked, “Why don’t you resurrect those great parodies of Marlboro and other cigarette brands?” And they invited me to have lunch with them in New York City? It was fun. And they then resumed doing those parodies.

I had a lot of other influences growing up. On the radio, Jean Shepherd (best known as the author and narrator of “A Christmas Story”) was kind of every adolescent’s hero. Every night, he would tell stories of his time growing up in Indiana, and I think that’s how I got a lot of my storytelling ability.

And reading newspapers. I would often buy all nine New York dailies on a Saturday just to see the different sportswriters’ take on the Dodger games and to see the sports cartoons by Willard Mullen in the World-Telegram & Sun. Some of these were resurrected in my exhibition, “Cartoonists Take Up Smoking!” .Also, I was a magician growing up doing birthday parties and school assemblies, inspired by my father who would do little tricks for his patients. I really loved that. Once I even got to open for pianist Peter Nero at the Rheingold Music Festival in Central Park. I wasn’t very good that night, but I still get to say I performed for 3000 people.

JC: Well, it’s clear that we take ourselves too seriously. We’ve lost the ability to look at ourselves and our culture with that kind of ironic distance. And in addition to that, when you were talking about the development of the Covid vaccine, the disinformation, to me, seems to be a malignant outgrowth of some of the technologies that we’ve developed and we’ve made accessible to the world, and the ability of people to spread disinformation with such great facility and power.

Alan: I think that we need to match the reality of the society that we’re living in with the strategies to counteract it, and I don’t think we’re doing that. We’re too ideologically split, and I don’t know where common sense has gone. I don’t think the media have risen to the occasion. Our newspapers are gone. I don’t do social media. But I just am horrified. I used to think I wasn’t very literate because I looked at all my fellow English majors, like you, Jack. They were omnivorous. I did pretty well, but I just never felt that I was that knowledgeable about poetry and literature. And I see now that I was pretty good compared to what people are spending their time doing today. There are no humanities to speak of in medical schools, except for the honors courses for the self- selected students who are already interested in humanities, and you and I have spoken about the fact that out of 22,000 entering medical students today only around 500 majored in a non-STEM field. It’s mind-boggling. It’s terrible.

JC: That brings up a point I’ve been meaning to take up in this interview, and that is, we’re both medical school professors. I’m emeritus. You’re still active. In my career, I have tried to imbue in students a love of humanities, the use of the arts and humanities to develop empathy, to develop reflectiveness and resilience. And of course, I’ve gotten a lot of feedback on that, or blowback, I guess I should say, because people say, well, that’s not going to work. It doesn’t matter. These guys are going out into a different medical world in which they are going to be subjected to stresses, to constraints and so forth. So even if they go into this with that kind of humanistic perspective, they won’t be able to effectuate it in their practice. And of course, having looked back on my career, it’s kind of difficult to hear that. I’m not sure that I believe it, but I wonder what your thoughts are on that matter.

Alan: Ann Walling has an excellent review article on ageism in the July 2024 issue of American Family Physician. She compiled a checklist of questions to ask an older person. She wrote it because she was struck by many of her older patients telling her how they did not feel respected by some of the younger physicians. But I noticed she didn’t include “How do you spend your time?” or “What was your occupation?” A person’s identity is paramount. I don’t think they consider their identity is being a patient.

I find that students are trained to be good mechanics about diseases, and that they can look up anything about diseases and how to treat them. But that doesn’t involve reading things that aren’t only related to the patient you’re addressing at that moment, and that doesn’t involve pleasure reading.

My point is that we no longer live, if we ever did, in the same neighborhood as our patients. We are in not just an ivory tower, but it’s got a moat around it, and they have to come to us. So I ask every resident, “How did the patient get here today?” And you know, after the first 20 or 30 eyerolls they realize it’s relevant. Or, “Who’s at home?” Many residents initially say, “That’s too personal.” This is family medicine that I’m talking about, and they’re saying to me that just asking who’s at home is too personal, or asking about the father when a newborn is brought in by the mother or grandmother or great-grandmother for a well-child visit is too personal.

You couldn’t get any further from my father’s education at Downstate in the 1930’s (when it was Long Island College of Medicine). He would walk two to three blocks to make house calls or even deliver babies. I may be romanticizing, but I think we’ve moved so far away from them, the patients, that now it’s all about us.

When I was a new faculty member at Baylor I didn’t know anything about Houston, so I started exploring the city. I began in January. By July, I proposed doing a community field trip for the incoming interns and new faculty. I chartered a school bus and took them to a Black radio station, an art museum, the city desk of one of the two daily newspapers, the county health department, the city council, the jail, and the criminal court. I did this for 12 years. I’d change the itinerary a little bit, and the only requirement was that they would write a reflective statement. When the residents were getting their exit interview from residency after three years, the community field trip – – that one day that they had as interns – – was one of the highest rated activities.

I think it’s so important to recognize with humility that we don’t know very much about our patients anymore. I’ll give you one quick example. I was attending in an ICU at Baylor and one of the residents was rattling off endless laboratory results. The patient was intubated, so we couldn’t talk to him. Finally, I just said, “Who is this patient? You’ve told me every laboratory result known to mankind, but you’ve never said a word about who he is.” Tomorrow morning, tell me who he is.” And I walked away, I was so angry.

And the next morning the resident excitedly said, “You wouldn’t believe who this guy is. He’s the architect who designed this hospital!” I mean, he was absolutely incredulous. And it wasn’t anything great that I’d said, other than to stop presenting people as numbers. Stop talking about people as “diabetics.” Just say, “the patient with diabetes.” It doesn’t take that much of a leap to talk about people with a disease, rather than who they are as a disease. And again, I’m not the first to suggest this, but it’s also astounding that we can’t dissuade residents from presenting people by race and gender. Warren Holleman, Marsha Holleman, and Bill Monroe wrote a terrific essay, a critique of how we present and discuss patients, in Literature and Medicine in 1992 called, “Is there a person in this case?”

JC: With regard to the bus trips and the field trips, in 1968 when I was a second year medical student at the University of Pittsburgh, we had a community and preventive medicine course in which weekly or biweekly we would go to nursing homes, to neighborhoods, like the so-called Hill District, which was the African American neighborhood in in Pittsburgh, and so on. What I’m trying to say here is that many of these ideas we’re coming up with and saying this would be something new, were practiced in the past, but have been lost. The other thing has to do with interviewing patients. I wrote an article in the early 1980s in the Annals of Internal Medicine called “Who is the Poor Historian?” And I pointed out that that when you’re interviewing a patient, which of you is the historian? Well, obviously, it’s the doctor who is collecting the data and who is trying to assemble and interpret it as a historian does. So again, this was 30 years ago.

Alan: This is so amazing. We should collect all these. One of my favorites is “well- developed, well-nourished and in no acute distress,” which should only ever be used to describe an infant in the neonatal ICU. Instead, imagine calling a woman “well-developed, well-nourished…” And you see this on every chart. This is what the dopey electronic medical records populate.

We are so beyond reclaiming the medical record. I did a grand rounds a few years ago about scribes. For the past decade, I’ve been privileged to have had an incredible experience with medical scribes. These are mostly pre-med students at the University of Alabama who have been one better than the next. One of them wasn’t even going to go into medicine but I urged her to apply, and she did. It’s a terrific way to help mold their thinking about medicine. I don’t like the idea of shadowing, which is passive, whereas being a medical scribe is a commitment, and it’s not easy. I’ve watched these students closely, and it has been a great joy. I confess that I initially opposed having a scribe, because I thought it was going to violate the patient-physician relationship and confidentiality. But it’s a wonderful experience that I wish we would be able to expand.

It’s absolutely astounding how we’ve become so absorbed in populating medical records with minutiae that very few people read. In auditing records of residents, I look past the templates. I want to read their narrative. I want to see that this was generated by a human being.

JC: My sense is that, as a result of my own experience, what we have done in teaching the human aspects of medicine and providing role models and images of what that could be, is that we have influenced a percentage of young medical students and residents who have been malleable in a way and made them better doctors. And that percentage, I don’t claim that it’s large, but I think it’s a real contribution.

We’ve talked a lot about the difficulties and the disparities and in a sense of atrocities, really, of modern medicine, but I’d like to leave this conversation with a positive note. So I guess I’d like to ask you, Alan, what kind of positive note can we end on from your experience?

Alan: You know, every day I must count my blessings. I give thanks for the opportunity to experience the moments that I get with patients, with residents, with colleagues. I’m

a critic, but I’m also probably the biggest fan of what we do in family medicine. When it was founded as a specialty in 1969, there was a kind of a nostalgia for, and resurrection of, the old general practitioner. So I’m really living at least in some way like my dad lived and appreciating these experiences with people. I don’t think medicine is anything other than that. I admire radiologists, especially those that want to see a picture of the patients that they’re reading the films on. I admire every sub-, sub-, sub- specialist there is, because, gosh, it’s good to know that if you need them, they’ll be there. But what a privilege it is to be able to see people from all generations at any given moment. I never know from one day to the next who I’m going to see, and on a single day about two years ago I actually saw patients of four generations in the same family: great grandmother, grandmother, mother and daughter. So I think that I’m a commercial for family medicine, but I’m not a commercial for making medicine into a disease-oriented, as opposed to a people-oriented, field. I think we can’t get to the diseases until we know who people are.

JC: I agree. I’m not sure we can return to the past or to the more holistic view that we recognize in your father and some of the doctors that I encountered when I was young. But I think we need to keep working and seize any opportunity that presents itself to get our message through. I’d like to thank you for this discussion. We could continue for several hours on these topics, and that would be very interesting, but in the interest of time, we have to conclude now. So thank you.

Alan: And I want to thank you and Lucy for thinking of me in this context. I also would be remiss in not thanking my wife, Doris. We’re going to be celebrating our 49th anniversary (in September 2024) with a few days in the Adirondack Mountains. Also, my three sons, Leon, David, and Sam, my late father and mother, Eric Solberg (my colleague and co-author in DOC for over 25 years), and the many mentors I’ve had: English professor Chick Chickering at Amherst College; cardiologist and poet John Stone at Emory University School of Medicine; Howard Rusk, the pioneering rehabilitation medicine physician in New York; Sam Nixon, a president of the American Academy of Family Physicians; and Bob Rakel, who was the chairman who took a chance on me after I was fired as editor of the New York State Journal of Medicine, even though I hadn’t worked in a hospital or clinic for several years.

I’ve been incredibly fortunate to have all these individuals in my life. There was also Kurt Deuschle, chair of community medicine at Mount Sinai School of Medicine. When I was fired as editor, I called him, looking for a few words of sympathy and encouragement. Instead, Kurt sternly replied, “It’s your own damn fault.” I was crestfallen and speechless. But then he explained, “You got too far away from patients.”

I’ve never forgotten that advice.

Alan Blum, MD, is a family physician and professor of Family Medicine at the College of Community Health Sciences, which also functions as the Tuscaloosa Regional Campus of the University of Alabama School of Medicine. He is the first holder of the Gerald Leon Wallace Endowed Chair in Family Medicine at The University of Alabama College of Community Health Sciences. One of the foremost authorities on tobacco problems, Blum is the director of The University of Alabama Center for the Study of Tobacco and Society, which he established in 1999.

Links
1964 Surgeon General’s Report
University of Alabama Center for the Study of Tobacco and Society
Irwin Redlener’s Bio on Wikipedia
Alan’s stories and sketches of patients 
Alan’s website about an artist who was a patient for over 50 years at the state mental hospital in Tuscaloosa

Intro photos from Covering Cancer? exhibition at Center for the Study of Tobacco and Society

For nearly two decades after the fatwa was issued, his literary career flourished, and he became a visible spokesperson for freedom of artistic expression. As president of PEN, Rushdie promoted initiatives to protect and promote the careers of writers living in fear under repressive political regimes. In August 2022, he was invited to speak on this topic at the Chatauqua Institution, an adult education and social movement. On a sunny summer morning, as he sat on the stage of the amphitheater to begin a public conversation with his interlocutor at Chatauqua, he noticed a man dressed in black suddenly rise up from the middle of the audience and charge the platform. There was no security at Chatauqua that day or any other day because the violent world had never intruded into the bucolic space of the institution during its entire 148 year history. Rushdie found himself rooted to the spot, frozen and unprepared to defend himself as the attacker stabbed him seventeen times – in his eye, his face, his neck, his chest, his abdomen, his hand. Heroic people charged the stage and subdued the assailant. Miraculously, Rushdie survived and he was helicoptered to the nearest trauma center for emergency treatment. Knife is a meditation on the event, the ordeal of rehabilitation that Rushdie had to endure, and his reaction now that he is healed, and his life is restored.

Knife is a visceral book that is grounded in the harsh reality of crazed, religious zealots and painful, tedious rehabilitation. It is different from the magical prose that characterizes much of Rushdie’s writing. The events are described in excruciating detail. One can feel the hurt and sense the worry etched into the pages. It is testament to the many doctors and nurses and therapists who took part in his bodily reconstruction and long convalescence. Most of all it is an inspiring testament to his wife who had the fortitude to be at his bedside throughout the entire ordeal . Rushdie gives her most of the credit for his stamina, the tenacity and resilience that he displayed during the long months after the attack. He substitutes an imaginary dialogue with his attacker in lieu of a face-to-face encounter in prison to express his contempt for his religious intolerance. Rushdie and his wife summon the courage to revisit the Chautauqua stage one year after the attack and achieve some degree of closure on the event.

There is much humanity and wisdom in these pages, lessons on how to confront and overcome adversity. One might question what we, mere mortals, can learn from a singular person like Rushdie who was blessed with such an abundance of human and professional resources to draw on as he recuperated from his injuries. However, differences in fame and access to expertise do not ultimately carry the day. Instead, it is how we as individuals, regardless of our wealth or social status, are able to tap our inner strength and utilize the help and support of our loved ones. The task for us all is to draw on our cognitive and psychological reserves and convert life-threatening tragedies into surmountable setbacks. If, like Rushdie, we succeed, then we will have reached a more mature and meaningful embrace of life in all its beauty and complexity. Rushdie’s story played out in the international limelight. The narrative also unfolds every day on countless hospital floors and rehabilitation units the world over as people strive to overcome injury and illness in their own private world. Rushdie’s template is universal.

But for readers of the Medhum website, I suggest that there is an unspoken but instructive message lurking in Rushdie’s story, specifically for health care providers, doctors and nurses both. There were unexpected turns of events during Rushdie’s recovery. It was not an uninterrupted march from near death to healing. He experienced disabling complications from medications that were prescribed for rational clinical reasons, iatrogenic problems. In one case, severe urinary retention requiring repeated painful bladder catheterization, it was only through the astute observation of one of the clinicians that the causative medication was stopped and the problem spontaneously resolved. In another, he experienced symptomatic hypotension, a disabling side effect of one of the drugs prescribed for him. There was a cancer scare when an imaging study performed to assess his urological problems. suggested he might have a lesion in his prostate. He experienced excruciating pain when his eyelids needed to be sutured together to protect his injured eye. In each case, Rushdie was reassured that things were proceedings according to plan and that things should improve with time. Follow up tests were done to monitor the prostate anomaly and confirm improvement in his symptoms but the discomfort and unease lingered in his body and his mind. The anxiety that the problems might not resolve was ever present in Rushdie’s consciousness. 

Doctors know that recovery from injury or illness is a time consuming process that rarely occurs overnight. They are right to encourage their patients to take the long view of their health problems, to reassure them the treatment is usually a continuing proposition. But even for a highly intelligent patient like Rushdie, the doctor’s confidence in how things were going could never completely allay the fear that his broken body would not heal, and his health would not be restored to what it had been pre-knife attack. Daniel Kahneman and Amos Tversky won the Nobel Prize in Economics in 2002 for groundbreaking studies that explored how people assess loss and gain and make financial decisions. Kahneman expanded on their studies in behavioral economics and proposed that rational thought utilizes two operational modes. System 1 is rapid and instinctive in contrast to system 2 which is slower, more deliberative, and more reasonable. Channeling this work by Kahneman, there may be two systems operating during recovery from bodily injury. Doctors may be employing an analog System 2 method of thought as the disease is steadily halted, reversed, and repaired. Patients, however, live through illness in a binary System 1 approach of thought: sick or back to normal. We physicians would do well to remember that the only words our patients really want to hear from us when they come to us for care are, “You are now fine. We can stop the medications and stop the follow up. You are back to normal.”

Knife
Salman Rushdie
Knopf 2024, 209 pages

One of the most successful patient-artists was Auguste Forestier, hospitalized at Saint-Alban at the age of 27 after placing pebbles on a train track and causing a train to derail.  After his discharge from treatment, Forestier remained at Saint-Alban for the rest of his life, where he worked in the kitchen. He began to create toys for the children of hospital employees using discarded materials, even butcher’s bones.  In this exhibition we see not only a boat created by Forestier from scraps of wood but also a print of Tosquelles proudly holding up one of Forestier’s boats.  

The work of Saint-Alban artists came to the attention of French artist Jean Dubuffet, who, after reading the 1922 book Art of the Insane, had founded the Art Brut (also known as Outsider Art) movement.  Dubuffet’s attempts to collect it were at first greeted with skepticism by Tosquelles.  However, the success of Forestier (eventually he even came to the attention of Picasso) was such that the profits from his work were used to help fund the hospital.   

At its previous venues in Europe (the show originated in Barcelona) a larger number of pieces from Saint-Alban were displayed.  At its US venue, the show has been augmented with work from American asylums, which prove to be a highlight of the exhibition.  Even without a Tosquelles to inspire them, these patients created beautiful and fascinating art.  

We see, for example, a coat made by Myrllen, a schizophrenic patient from Tennessee.  The patient had reportedly worsened in response to such few treatments as were available at the time.  In desperation, she was given discarded rags and threads.  What she produced gives us a window into her condition, with strange words and figures whose meaning was known only to her.  Ironically, after making several such pieces the patient lost her creative impulse and stopped sewing once put on Thorazine, the first antipsychotic medication.   

Another piece, a watercolor entitled “An Antarctic Scenery,” is one of the earliest known American asylum paintings (c. 1816).  The patient-artist, Richard Nisbett, in his paranoid imagination has chosen to depict “a fleet of murtherous Pirates” invading Antarctica. Nisbett was a patient at Pennsylvania Hospital in Philadelphia under the treatment of none other than Benjamin Rush, often considered to be the father of American psychiatry.  

Although the exhibition closes in August, a book (which will be for sale at the Museum and online) is expected to be released in November 2024.  The link to a virtual conversation with the show’s curators is given here:  https://www.youtube.com/watch?v=s9j3fMn0xJA (1 hour 19 minutes).

Francesc Tosquelles is frequently mentioned in The Rebel’s Clinic, by Adam Shatz,  a recent biography of the psychiatrist, Frantz Fanon.

A Tosquelles Glossary from the Barcelona exhibition is also a helpful tool: https://www.cccb.org/en/exhibitions/guide/francesc-tosquelles/237849 

Illustrations: 

Auguste Forestier (1887–1958, France) Untitled (Boat), 1935–1949, Wood, fabric, metal, leather, nail, 29 1/2 x 45 1/4 x 9 1/2 in. Centre Pompidou, Paris, Musée national d’art moderne/Centre de création industrielle, ART BRUT/Gift of Bruno Decharme in 2021, AM 2022-43. 

Romain Vigouroux (active mid-20th century, France), Francesc Tosquelles on the Roof of a Building at the Saint-Alban Psychiatric Hospital, Holding a Sculpture by Auguste Forestier, 1947, Gelatin silver print, 7 x 4 7/8 in Collection Family Ou-Rabah Tosquelles. 

Richard Nisbett (1753 England-1823, United States) An Antarctic Scenery, 1816, watercolor.  Collection of The Library Company of Philadelphia.  

American Folk Art Museum  
Lincoln Square, New York, NY 10023
Folkartmuseum.org

At bottom, these two categories of judgment largely overlap. My concern here is the role of the physician’s own emotions (or, as we like to say in medicine, in order to sanitize them, affects) in judgments of either category. Do the physician’s own emotional responses contaminate her judgment when making clinical or moral decisions in patient care? Or, rather, do her emotional states constitute essential components of medical judgment? 

Clinical Judgment 

Medicine has a long tradition that attributes a special quality to the diagnostic and therapeutic thought processes of good clinicians, an attribute independent of intelligence or medical knowledge. Traditional views of clinical judgment included personal experience, received knowledge in the profession, and evidence from empirical studies. Emphasis was put on developing the “clinical eye” or clinical intuition as a result of personal experience, perhaps guided by role model physicians. In 1967 the Yale clinician and epidemiologist Alvan Feinstein published his book, Clinical Judgment, which was the first (as far as I am aware) systematic and scholarly analysis of judgment in medicine.¹ What Feinstein added to the mix was a firm grounding in epidemiological methodology; notions like prevalence, sensitivity, specificity, predictive value. What constituted evidence became more scientific and less subject to bias. However, Feinstein acknowledged the important influence of a personal relationship with the patient in good clinical judgment. 

In this sense he was following a tradition that has been prominent among physician writers for over 250 years and was often expressed metaphorically by reference to the heart. For example, John Gregory, Professor of Medicine at the University of Edinburgh wrote in 1772: “Of the physician’s character, the chief quality is humanity, the sensibility of heart that makes us feel for the distress of our fellow-creatures, and which, in consequence, incites us… to relieve them.” Physicians “by being daily conversant with scenes of distress, acquire that firmness of mind so necessary in the practice of physic.”² Yet he warned his readers to maintain “a gentle and humane temper” because “rough and blustering manners generally accompany a weak understanding and a mean soul.”² In 1803 Gregory’s student, Thomas Percival, instructed physicians to, “Unite tenderness with steadiness in your care of patients and cultivate the tender charity that the moral practice of medicine requires.” He warned his readers that medical practice makes the practitioner vulnerable to “coldness of heart,” and he concluded: “This coldness of heart, this moral insensibility, should be sedulously counteracted before it has gained an invisible ascendancy.”³ 

Physicians reiterated this dynamic throughout the nineteenth century. Morril wrote that “the study of medicine has a peculiar tendency to harden the disposition,” which makes it incumbent on students to cultivate “an affectionate sympathizing spirit,” while Jones reflected on medicine’s “manifest tendency to harden and corrupt the heart.”⁴ And famously, in his 1889 graduation address at the University of Pennsylvania, William Osler encouraged the graduates to cultivate the virtue of “aequanimitas,” which would assist them in meeting, “the exigencies of practice with firmness and courage without, at the same time, hardening the human heart by which we live.”⁵

In the early twentieth century, Francis W. Peabody, chief of the Harvard medical service at Boston City Hospital, published an influential description of this tension between the “intensely personal” values needed in caring for patients and the “entirely impersonal” aspects of treating disease. Peabody recognized that the hospital setting creates a hostile environment for humanism, but urged students to commit “time, sympathy, and understanding” to creating a “personal bond” with their patients, which will make them more effective healers, as well as give them personal satisfaction.⁶ This tradition was most recently and eloquently summarized in A Flag in the Wind, Thomas Inui’s now famous report to the American Association of Medical Colleges (2003).⁷ Each of these writers emphasized the importance of tenderness or sensibility of heart, while warning students and practitioners against the tendency of medical practice to chill, harden, or corrupt the heart. 

A second tradition, almost diametrically opposed to the first, experienced a growth spurt in the mid-twentieth century and has become the most prominent model for medical education and practice in recent decades. In terms of diagnosis and therapy, the ascendency of randomized clinical trials, statistical techniques for the metanalysis of multiple studies, evidence-based medicine, algorithms, and clinical decision rules has progressively reduced the role of judgment in medicine because decisions are presumably to be based on complete, rather than incomplete, knowledge. Judgment is to be replaced by decision rules that can be applied without the adverse influence of spooky elements like intuition, biases, experience, emotion, or idiosyncratic beliefs. 

In tandem with this, the doctor’s proper stance toward her patient became detachment, rather than personal engagement, and the doctor’s emotions became stumbling blocks, rather than beneficial to care. This tradition holds that emotional experience decreases objectivity, which harms the patient because it compromises clear thinking and harms the physician because it makes her vulnerable to emotional stress, depression, and burnout. In summary, what was once a pernicious tendency to harden the heart is no longer considered pernicious, but rather a positive development that should be fostered by medical education.^8-11 Clinical judgment, according to this tradition, should ignore the heart and focus exclusively on the mind. 

Moral Judgment 

Medical morality originated in ancient writings from Greece, India, and China that specify the personal traits and moral duties of medical practitioners. These documents include such duties as honoring their teachers, acting in their patient’s best interests, and keeping “whatever I shall see or hear in the course of my profession” confidential. These admonitions were later incorporated into a Judeo-Christian-Islamic framework that added a theological dimension (e.g. respect for human life, compassion, fidelity, and vocation) to medical morality—for example, in the Oath of Maimonides: “May I never see in the patient anything but a fellow creature in pain.” Or, in the Islamic oath, “I swear by God to be . . . an instrument of God’s mercy.” This work was secularized in the eighteenth and nineteenth centuries by writers who adapted Aristotelian virtue theory to the profession. The basic idea, then, was that learning to be a physician involved a process of character formation in which certain defining virtues were incorporated as personal traits or qualities, thus enabling physicians to make correct moral judgments in their professional lives. 

This work was brought up-to-date in recent decades by philosophically-minded physicians, like Edmund Pellegrino¹² and Eric Cassell^{13, 14}, who argue that judgment in medicine should be an instantiation of the Aristotelian intellectual virtue called phronesis, or practical wisdom.⁹ They remind their readers of the moral goals intrinsic to the profession, and that certain physician character traits or virtues further those goals, e.g. compassion, fidelity, integrity, courage, humility, self-improvement. They argue that, in fact, that all clinical judgment is informed by moral judgment. 

Although moral judgment was thought essential in deciding what to do for patients, it was proscribed in making decisions about the intrinsic value of patients. The ethos of medicine strongly warns against judging the patient’s personal worthiness or value, even if the physician considers the patient’s beliefs or actions hateful. Thus, professional ethics dictates that you remain detached from any behavior that would compromise treatment of enemy soldiers, criminals, terrorists, or patients that you find personally hateful or disgusting. 

Beginning in the 1960s and 1970s, the professional virtue tradition was supplemented by (or challenged by, depending on your perspective) a new moral framework that generally goes by the name biomedical ethics. This development became necessary for a variety of reasons, most notably (a) technological advances in medicine that enhanced the ability to prolong life and especially to harm, as well as to help, patients; (b) new societal emphasis on individual and civil rights; (c) increasing opportunities for conflicts of interest in medical practice; (d) revelations about medical research conducted without the subjects’ knowledge or adequate consent; and (e) concerns about the lack of equity in the provision of health care services. 

The biomedical ethics movement involved a concerted response to these issues by a great number of moral philosophers, theologians, legal theorists, and physicians. In the United States the movement acquired its canonical form as a result of the publications of two bodies, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974-78) and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1978-1983). The former developed the ethical framework (i.e., Common Rule) that has since guided all research involving human subjects. The latter delineated and elaborated four basic ethical principles: respect for autonomy, beneficence, nonmalificence, and justice. 

In biomedical ethics the focus is entirely on explicit justification of individual decisions (i.e. who should make them, what principles should be invoked), rather than on the qualities or character of the decision maker. Importantly, the model is one of shared decision making between patient and clinician, with adult patients having the determining voice, unless they lack decision making capacity. 

The notable aspect, for my purposes here, is that principles, like respect for autonomy, are intellectual constructs rather than personal traits, like virtues. There is no explicit role for such traits in biomedical ethics. I take it that virtues like compassion, empathy, humility, or courage cannot be actualized without an emotional component. You cannot act compassionately without experiencing some feeling. Thus, while traditional medical morality highlights sensibility of heart, biomedical ethics (at least in theory) exclusively involves intellectual considerations. Principle-based biomedical ethics is often labeled “thin” because, theoretically at least, it leaves out particularistic features of the patient’s community, culture, beliefs, and personal story. Advocates of care, feminist, and/or narrative ethics maintain that such features have great moral relevance to health care decisions. They argue for a “thick” form of health care ethics that takes particularities into account.

“Thickness” in decision making applies to physicians in decisions about the best (or most virtuous) way to allocate their time and effort. Part of this thickness relates to the physician’s feelings, emotions, or “tenderness,” to use Thomas Percival’s term. Consider the following case example. 

Case Example 

The case is an excerpt taken from “Narrative Medicine and Negative Capability,” an essay by the cardiologist Terrence Holt.¹⁰  Holt illustrates his discussion of the complexities of moral judgment in medicine by describing a situation he once experienced when he was a resident in the cardiac ICU: 

“It is about eleven in the morning, and I have been up since six in the morning the day before. The patient has been under my care eleven days… About fifteen minutes earlier, in response to her request and after several days of discussion, I had asked the nurse to turn off the pump that had been keeping her alive. The family members are around the bedside. The patient is awake… She will probably be dead within the hour. 

Tears are coursing down my face. I am being very quiet about it, but in a very quiet way I am sobbing as freely as I know how. I’m determined to stay with the patient during this ordeal. But meanwhile I am thinking: This is crazy. I’ve got several unstable patients who need attention. And there’s that arterial line in twenty-four that needs changing… At the same time I am utterly sad, haunted by memories of my father’s… death ten years ago. 

But somewhere a voice is also thinking: I’ll never get to lunch at this rate. I’m so backed up I’ll never get out of here on time.”¹⁵

Reflections 

I want to reflect on several aspects of Dr. Holt’s judgment in light of the clinical and moral traditions that I have outlined. First, the writer appears to combine deep emotional experience with a sense of detachment. He experiences (a) feelings of sadness and compassion, (b) awareness that at least in part those feelings arise from grief over his father’s death, and (c) detached reflection about his own needs and the work he has to do that afternoon. This combination appears consistent with older admonitions that physicians should maintain “sensibility of heart,” but to be at variance with the contemporary belief that emotional connection with patients is incompatible with good judgment—assuming, of course, that his current choices constitute good judgment. Do they? 

Second, from the perspective of contemporary biomedical ethics, Dr. Holt had already fulfilled his ethical duty when he respected the patient’s right to refuse treatment, and consequently withdrew mechanical ventilation. In addition, he may have consciously employed the principle of nonmalificence if he believed that the respirator was only prolonging the patient’s suffering. He has no moral duty to maintain a compassionate vigil. In contemporary terms, his actions would be considered supererogatory—commendable, but not a moral duty. 

Third, but how commendable is his behavior? It is clear that Dr. Holt’s course of action could have arisen, at least in part, from unresolved emotions related to his father’s death ten years earlier. He admits to strong feelings of sadness, loss, and grief, even to the extent of crying. Is this a case of countertransference, a psychological defense mechanism, rather than a true expression of moral virtue? We need to consider the extent to which the emotions about his father’s death are nurturing appropriate compassionate behavior, or, alternatively, contributing to a form of hyper-compassion that is preventing him from attending to other duties. 

Fourth, this brings us to the question of harm. Given the level of criticality among his ICU patients, Dr. Holt’s compassionate vigil has a reasonably high risk of negatively impacting the others’ care. He does, after all, have an established duty to provide the best medical care he can to each of his other patients in the ICU. They all have identified and pressing needs. To what extent, if any, does his behavior represent an abrogation of his duty to others? In bioethical terms, he may well be discounting the ethical principles of beneficence and justice in his desire to demonstrate compassion. 

To demonstrate this, we can take the narrative a step further. Suppose the man whose arterial line needed to be changed (e.g. nurses have noticed local redness and swelling) develops septic shock shortly after the first patient dies. Dr. Holt has spent more than an hour in the room with the dying patient and his family. Did his delay in removing the infected arterial line precipitate the septic shock? Perhaps it could have been averted had he changed the line earlier that morning? Has his compassion for one patient and his family caused a life-threatening complication in another? 

This leads to a fifth consideration. Let’s return to the concept of clinical judgment as being informed by phronesis, a type of wisdom relevant to practical things, requiring an ability to discern the right or virtuous action in a given situation. Thomas Aquinas considered phronesis to be equivalent to prudence, and medical writers like Pellegrino tend to use the terms interchangeably. Pellegrino and Thomasma, in The Virtues of Medical Practice, describe prudence as the virtue that fosters the ability to choose the right way of acting.11 From this perspective, was Dr. Holt’s decision a prudent decision? Would it have been more prudent to excuse himself and go tend to his other duties? 

Sixth, let’s look briefly at Dr. Holt’s situation through the lens of narrative ethics, which is a relatively new perspective that highlights medicine’s traditional focus on particular cases or stories as providing the context for individual judgments.12 In this framework, Dr. Holt’s actions make for an engaging story. There is little doubt that his response to what is going on with the patient and his family suggests a more affirmative and inspirational narrative than had he chosen to continue with his ordinary duties. This version is more comforting for the patient and his family, it is more personally fulfilling for the doctor himself, and more compelling for the reader than the more prudent alternative. For better or worse, heroic or passionate behavior is generally far more interesting than prudent behavior. Does that make it right? 

Conclusion 

Judgment in medical practice is complex and omnipresent, involving decisions that range from diagnosis and treatment of illness to the assessment of relevant patient characteristics and choice of appropriate words. A great deal of this judgment has an important moral dimension. In this paper, I have argued that medical judgment also frequently integrates emotional content into the decision-making process; and the role of emotion can be important and beneficial, rather than damaging. In fact, traditional medical virtues – e.g., compassion, fidelity, courage, humility – are habits of the heart that are intrinsically associated with emotion, as well as rational cognition. 

The case I have presented illustrates this complexity. It also illustrates the role of incomplete knowledge in medical judgment. For example, if we knew more about the benefits and risks of Dr. Holt’s actions, we might come to a more definitive judgment about whether, under the given circumstances, his clinical/moral judgment was right or wrong, correct or incorrect. Surely, respecting the patient’s decision to discontinue the ventilator was morally right, but what about his subsequent decision to spend considerable time with the patient and his family, while postponing other duties? Well, that is a question of judgment.

References

1. Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967.
2. Gregory J. Lectures on the duties and qualifications of a physician. London, W. Strahan and T. Cadell, 1772. [Reprinted in McCullough LB (Ed.) John Gregory’s Writings on Medical Ethics and Philosophy of Medicine. Dordrecht, Kluwer Academic, 1998.]
3. Percival, Thomas. Percival’s Medical Ethics. Ed. C. D. Leake. Huntington, NY: Robert E. Krieger, 1975.
4. Warner JH, Rizzolo LJ. Anatomical instruction and training for professionalism from the 19^th to the 21^st centuries. Clinical Anatomy. 2006; 19: 403-414.
5. Osler W. “Aequanimitas,” in Hinohara S, Niki H (Eds). Osler’s ‘A Way of Life” & Other Addresses With Commentary & Annotations. Durham, Duke University Press, 2001., pp. 21-29.
6. Peabody FW.  The care of the patient. JAMA. 1927; 88: 877-882.
7. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges, 2003.
8. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994; 69: 861-871.
9. Coulehan J, Williams PC. Vanquishing virtue: The impact of medical education. Acad Med. 2001; 76: 598-605
10. Coulehan J. Williams PC. Conflicting professional values in medical education. Cambridge Quarterly of Healthcare Ethics, 2003; 12: 7-20.
11. Coulehan J. Today’s Professionalism: Engaging the Mind, but Not the Heart. Acad Med. 2005; 80: 892-898.
12. Pellegrino ED, Thomasma DC. The Virtues in Medical Practice, Oxford University Press, 1993.
13. Cassell EJ. The Nature of Suffering and the Goals of Medicine, 2^nd edition, Oxford University Press, 2004.
14. Cassell EJ. Doctoring. The Nature of Primary Care Medicine. Oxford University Press, 1997.
15. Holt TW. Narrative medicine and negative capability. Lit. Med. 2004; 23(2): 318-333.
16. Jones AH. Narrative in medical ethics. Brit Med J. 1999; 318: 253-256/
17. Lothe J, Hawthorne J. Narrative Ethics, Value Inquiry Book Series, Rodopi, 2013

EDITOR’S NOTE:  This essay is taken from a paper presented in 2020 by the author at the Joske Colloquium, a gathering of physicians, philosophers, historians, lawyers, social scientists, and creative writers that met biannually at the University of Tasmania from 2002 to 2020 to discuss broad topics of human experience and flourishing.  We feel that it nicely supports and illustrates some of the philosophical underpinnings, multidisciplinary nature, and real-life applications of the field of medical humanities.  

Photos from Wikimedia. CC BY-SA 3.0.

Paul Harding uses this disquieting episode as the basis for his latest novel, The Other Eden. Harding is the author of Tinkers, his debut novel which was published in 2009 by Bellevue Literary Press. That book was awarded the Pulitzer Prize, a unique achievement for a book that had been published well outside of the mainstream. His setting is called Apple Island, and the founders are Benjamin Honey, a freed slave, and his Irish wife Patience Raferty who arrive on the island in 1792. They survive a monstrous storm and flood in 1815 and together with a handful of families build a community that over the next 100 years is able to endure and thrive in the face of the harsh elements that confront them.

The descendants of the Honeys are the most prominent characters in Harding’s narrative. The current matriarch, Esther, spends most of her time brooding in a rocking chair, keeping watch over her family, and vigilantly guarding a secret about her son, Eha. Eha is a carpenter, who partners with another resident on the island to build all of the homes for the residents; this partner is an older man who lives alone sheltered inside a hollowed-out tree and who has carved an intricate circular mural that coils upward along the trunk of his home.  Ethan, Eha’s 15-year old son, is a precociously talented artist who is alert to nature and his surroundings and constantly putting images to paper. His two younger sisters are always on the go and playing with the children of three other families.

The outside world intervenes in this quiet secluded world when a team of officials from the neighboring town of Foxden on the coast comes to Apple Island with a mission — to investigate the health and well-being of the inhabitants. They are primed by an entrenched belief that there are certain people in society who are innately better and the consequent dangers of mixing races and inbreeding over several generations. With this in mind, the town representatives conclude that it is in the best interest of all concerned to condemn the Apple Island village and disperse its inhabitants. This is the only solution that they believe will prevent future generations from being adversely affected by the downward spiral of human intellectual and moral capacity and that will avoid the spread of this social contagion beyond the confines of the island. Interwoven with this depressing storyline, there is an effort by a local minister to rescue Ethan from Apple Island because he is very fair-skinned. He may be able to pass as White and his artistic talent may enable him to overcome his “flawed” racial beginnings. Needless to say, the path to a tragic ending is patiently laid out by the author. But Harding’s genius is to make us appreciate the deep humanity and abiding love that the inhabitants of Apple Island sustain even though they cannot escape the colony’s ultimate demise.

A plot summary cannot do justice to the beauty and power of Harding’s prose. His principal characters are simple people living  a subsistence existence. But they are embedded in a lushly evoked environment, and they are attuned to the rhythms of nature and the cycles of daily human life. The emotions are deeply felt, and the action rings true; the inhabitants of the island are not cardboard heroes or angels. There is a threat of violence lurking just below the surface that can emerge with shattering force when triggered by unexpected events.

Ethan’s story is presented as a complex mixture of personalities and motivations. The minister who comes to Apple Island to tutor the children and who devises the plan to rescue Ethan from life on the island recognizes the remarkable native intelligence of his school-age pupils, one who is literate in Latin, another who has mastered geometry. But he painfully admits in his private journal to deep feelings of revulsion when he is surrounded by the black and mixed race children in school. When Ethan is relocated to the home of a wealthy family on the mainland to continue his art education, he becomes more than friends  with one of the servant girls, Bridget. There is a familiar element to their story, but the last stage is surprising and moving in its depiction of devotion and steadfastness in the face of love and separation. Ethan’s fate is mysterious, but his drawings live on in museum exhibitions.

The underlying motivations of the mainlanders who come to survey the living conditions of the people on Apple Island are clothed in their seemingly noble aspiration of improving the lot of humanity.  They use the language of social Darwinism to defend their eugenics agenda, and this is no simple literary plotline. The eugenics movement in the United States was widespread and widely accepted; the nation became obsessed with the concept of “fitter families” and the dangers of reproduction of the unfit, and over 60,000 “feeble minded” individuals were involuntarily sterilized in early twentieth century America. The horrible consequences of flawed science and mistaken beliefs about biology and intrinsic human worth are made abundantly clear. But Harding’s writing rises above formulaic condemnation or pedantic instruction to the reader. He makes you live the experience and the suffering of the islanders whose humanity is so grossly ignored by the team of experts sent to learn about them and then deal with them.

Many reviewers of The Other Eden have commented on the mythic nature of the book. I think they sell Harding short. I think his accomplishment is far greater. His writing is almost Biblical in nature,  in the sense that Marilynne Robinson describes biblical writing in her recent book Understanding Genesis (Farrar, Strauss, and Giroux, 2024). In that work, Robinson marvels at how all of the events that unfold in Genesis occur under divine guidance and plans, yet  the men and women maintain their independence to act and influence their fate. God and  humankind are in a covenantal relationship. Each has the capacity to surprise, to rise above their circumstances, defy expectations and even act out of love and forbearance when circumstances might dictate revenge and retribution. Similarly, Harding’s literary world is infused with the powerful belief in human agency and decency, concepts in direct counterpoint to the biologic determinism to which the mainlanders subscribe

The Other Eden evokes many Biblical narratives and themes. Apple Island grows out of a flood and the inhabitants are dispersed after the decision is made to end the colony. There is demonic evil and the threat of servitude, with the image of an enslaving Pharaoh lurking over the heads of the investigators from Foxden. There is branding at birth, deception of elders, scheming to save a favored child, and banishment of a disgraced woman. Noah, Abraham, Jacob, Moses, Pharoah, and Ruth are hovering over the residents of Apple Island. Harding uses all of these archetypal tropes and personalities. But like all good Biblical narratives, the images serve to construct a human world that speaks to all of us. The Other Eden is more than a foundation myth. It is a chronicle of living.

THIS OTHER EDEN
Paul Harding
W.W. Norton and Co.
2023
221 pp (paperback)

Web Photo by Seth Dewey

Kline opens with the shocking practice of team doctor Larry Nassar (1963-), pedophile and serial abuser of the gymnasts under his care who successfully took him down in 2017. He is serving decades in prison, where he was stabbed multiple times in 2023. She continues with the story of the Johns Hopkins University gynecologist Nikita Levy (1959-2013) who secretly photographed (or filmed) his patients’ genitalia with cameras concealed in pens that he wore on a lanyard around his neck. Abruptly fired when the story came to light, Levy died by suicide in 2013. Two years later 9000 victims were awarded a class-action settlement of $190M.

 It is not surprising, albeit horrifying, that such abuse could emerge in a medical specialty that centers on the most intimate aspects of women’s healthcare.  In a sequence of readable chapters, each of which could stand alone, Kline examines medical achievements in women’s health that could be (and have been) told in triumphalist tones: the speculum, gynecological surgery, the Pap smear, and oral contraceptives. All were invented by men. She also includes marriage counseling and patients as lay instructors in pelvic exams, both initiatives also promoted by men.

Without denying the potential value of these innovations, Kline brings every chapter into the present with the voices and actions of women who object because of painful incursions upon their bodies, denial of their humanity, and distortions of power. Her sources include archives, journals, histories (many written by women scholars), interviews, patient stories, and artistic creations—objects, music, films, poetry. Issues of gender, race, and class pervade the analysis.

The nineteenth-century inventions of the much-maligned J. Marion Sims (1813-1883) end with the 2018 dismantling of his Manhattan statue and the 2022 unveiling, in Montgomery, Alabama, of Michelle Bowder’s Mothers of Gynecology in honor of the three slaves who had been his research subjects. The chapter on Robert Battey (1828-1895) cites the critical secondary literature on how his procedure to remove ovaries by the vaginal route became vastly overused for all female complaints, even mental illness; however, it also draws upon his papers, kept in Atlanta, allowing the reader to comprehend how his initial motivation was to end the menstrual cycle for patients.

Similarly, Kline explores the previously unexamined papers including numerous drawings and photographs of R.L. Dickenson who strove to comprehend female sexual response while purporting to avoid prurience. As much as we are put off by the excruciating details of his oeuvre, letters from grateful patients demand reconsideration of his efforts to understand female sexuality.

The Pap test, which detects early cervical cancer, and the birth-control pill both advanced women’s healthcare. Yet they each prompted reactions from lay women: the failures and inaccessibility of Pap testing and consequent delays in diagnosis, resulted in cervical-cancer survivors‘ organizations; the impersonal implementation and insistence upon regular pelvic examinations spurred the vaginal self-examination movement. Kline lays out the medical achievements and plunges into the social reactions through interviews with the founders and leaders of these activist groups, tracking them down internationally. They express the militant goal to avoid the gynecologist (as if they are all brutal), and the unalloyed joy of seeing one’s own cervix (without the benefit of cytology). Some activists called for men to be banned from the specialty. One wonders if the strident anger and hostility directed at male professionals, many of whom try to practice with compassion and care, may well have incited previously unfelt, reactionary attitudes in the practitioners.

The use of surrogate patients for teaching history-taking and physical examination was proposed and advocated by Harold Barrows in the mid-1960s. A decade later, once academic and professional gynecology accepted the complaints of activists, it followed the trend and began to engage lay women as teaching assistants on how to perform pelvic examinations. Kline outlines Robert Kretschmar’s extension of the trend to pelvic examination at the University of Iowa. She also describes the Pelvic Teaching Program of Harvard and its involvement of the Women’s Community Health Center (WCHC). Even there, we read of pushback and disillusionment as relationships soured. What kind of a woman would do that? – and why? The originally enthusiastic female participants were underpaid and treated as passive objects rather than instructors. Prostitutes had been engaged, as well as gender activists who “started feeling like [they] were in the same positions as are prostitutes….and then started saying ‘Yeah, we are. We are.’” (p. 206) The professors eventually learned to quietly observe, but the students themselves tainted the experience with sexual inuendo and disrespect. Kline provides statistics on how widely lay instructors are used today.

Also using statistics, she exposes today’s teaching of the pelvic examination on anesthetized women who have not given consent. Although the American Association of Medical Colleges deemed the practice unethical in 2003, it is still widely used, most often on racialized, “public” patients.

Kline also highlights the medical, social and financial obstacles to care for transgender people.  Citing surveys from 2015, she reminds readers that most medical students receive no training on care of trans people and that trans men should receive Pap tests but most do not, because of their own discomfort and the ignorance of health care professionals.

Under Kline’s gaze, the benefits of each medical achievement tend to unravel in clinical practice. She rarely outright condemns or criticizes the physician actors; however, she uses irony, targets hypocrisy, and never fails to highlight the opportunities for self-promotion within the benefits that they provided to their patients. Just as she observes gynecologists second-guessing or failing to believe their patients, she views their own stated motives and goals with skepticism. Instead, she allows the male physicians to skewer themselves in their own words with choice quotes. Believing his patients’ pains were psychological, James C. Wood described how he cleared a clogged ward: “’I wanted their beds above all things for real surgical cases, and I knew not one of them wanted to be cut’ So he started scheduling them for various surgeries and, within a week, all ten beds were ‘well emptied for legitimate hospital use’” (p. 102).

Issues of power, trust and consent underpin the fallout of these stories and explain why many women avoid pelvic examination despite its undeniable advantages. In a counterpoint to the miserable tales of criminals at her opening, Kline closes with a patient’s tribute to a sensitive gynecologist on Martha’s Vineyard. The patient has long suffered from an iatrogenic injury owing to the diethylstilbestrol (DES) treatment given to her mother during pregnancy. Her doctor, Dan Pesch, listens well, comprehends her justified fear, grants her control over decisions, and yet manages to wield all the advances of last two centuries to catch her cancer early. Compassion, Kline observes, “can literally save lives.”

Now—will she next expose the hidden history of the prostate exam?

Exposed: The Hidden History of the Pelvic Exam
Wendy Kline
Cambridge and Hoboken: Polity Press, 2024.