patient care – medhum.org

Meet the MedHum Team: Dr. Jack Coulehan

Dave Hsu — Mon, 16 Feb 2026 14:07:42 +0000

Jack Coulehan, poet and Professor Emeritus of Family, Population, and Preventive Medicine sits down with David Hsu to talk about Medical Humanities. This is a lightly edited version of their conversation.

DAVID HSU: What are you up to these days? What are you working on?

Jack Coulehan

JACK COULEHAN: In terms of creativity, I’m working on a new collection of poems that I’m editing now. I’m also the book review editor of The Pharos magazine, and that takes up an unexpectedly large amount of time.

DAVID HSU: Do you practice medicine at all anymore?

JACK COULEHAN: No, actually, I retired about 12 years ago now, but I do still teach medical students as a volunteer. It’s a class that I began back when I started at Stony Brook in 1991. It’s called Medicine in Society, and it’s a first-year seminar course that deals with human, social, and interpersonal issues in medicine. We use a lot of literature and film in that and so I’m still a group leader. We also have a master’s degree program in medical humanities, and I teach a course in that. So I still keep my hand a little bit in teaching.

DAVID HSU: Given that you’re doing all this work in the humanities, what do you think about the relationship between medicine and the humanities?

JACK COULEHAN: You know, that’s a surprisingly difficult question for me, because I’ve always had this kind of love/hate relationship with the term medical humanities, because I think it doesn’t quite capture the problem or the issues that we’re trying to address and what we do. In a lot of my work, I tend to cite a piece that Rafael Campo wrote in JAMA in 2005, entitled “The Medical Humanities, For Lack of a Better Term.” What I’ve really always thought is that what we’re trying to do is to teach students and ourselves, really, to become more reflective and more thoughtful…[Campo] used the terms reconnection, renewal, and meaning. . I think we’re not necessarily encouraged in our profession to become aware of our own needs, to become reflective, thoughtful, to become focused on the personhood of patients and so on. And so I think, through discussion, through examples in literature, film, etc., we can really try to address these issues. I guess the term medical humanities is fine as a placeholder, but I wish there was a better term for it. But, aside from reflecting on the name itself, those are the things I think we’re trying to address in medical humanities.

When I started in this business, pretty long ago, I was thinking about [medical humanities] mostly in terms of becoming a better doctor by improving one’s empathic skills and reflecting on the patient as a person. But as time has gone on, I’ve become more aware that I think it’s really something that makes you a better person and also more able to cope with the stresses and the challenges of modern medicine. So, I think it works both ways.

DAVID HSU: What are your criticisms of the way medicine is practiced now, since people aren’t doing all this [reconnection, renewal, and meaning]?

JACK COULEHAN: First of all, I think medicine has to be understood in our current overall culture of increasing subspecialization and focusing on narrower and narrower fields [of practice], using more and more technological instruments, tools, and machines. Also, medicine is more and more controlled by larger interests that are not necessarily oriented towards the primary values of medicine. There are virtually no constraints on the use of technology, the focus is entirely on disease, on narrow perspectives on disease.

What I’m saying is that all this detracts from the ability necessary to see the patient in terms other than as an object that has a disease or a person who has a specific problem that needs to be addressed.

Just to give my personal examples, when you get to be 81 years old, as I am, you have a lot of opportunities to experience being a patient. I saw a cardiologist a couple of weeks ago who is an older cardiologist, and he was what I would call an ideal physician. He does interventional cardiology, he’s a professor, well-published, and yet his approach, I would consider to be very therapeutic–very positive, trusting and good eye contact. He wasn’t looking at the computer. He was just a genuine person, genuinely interested. I’ve also gone to a urologist who was just the reverse. Equally specialized in the same medical system, but one who was all about the particular issue, the particular organ, and the particular thing that’s happening to that organ.

It’s possible, you know, when you start talking about the kind of values and the kind of stresses that modern physicians are under, the first response you get is that, “Oh, yeah, that’s great. That’s what we should do.” But you know, we only have 15 minutes [and] we have to deal with the EMR, etc. But that belies the fact that there are physicians out there who are very good at actual doctoring and others who aren’t, and I think that’s because, well, let’s say, look at those two things on a spectrum…I would say that there is the opportunity, even in today’s world, to help students keep their belief, which most of them have, I think, when they begin, that doctoring is really interested in persons. And I think we could increase the percentage of physicians who feel that way and practice that way.

DAVID HSU: I’m curious because you mentioned that you’re 81. You’ve been around the medical system for decades. How has the system changed from when you first started in it until now? Is it getting worse, or has it always been like this?

JACK COULEHAN: Well, that’s tough. I definitely think it’s worse, but I also think it’s romanticism, you know, to look back and say, “Oh the good old days.”

I graduated from medical school in 1969 and graduated from my residency and fellowship in 1975. Those were the days when I was learning to take a history. Taking a history–that’s another phrase that I dislike. But we had a little black book, that had 100 or 140 questions to ask in it. There was no concept of medical interviewing, nor the teaching of it. I had the feeling that a lot of the values of good doctoring were kind of implicit and not necessarily taught in those days.

And so we’ve gone through a whole phase of learning that the medical interview is a therapeutic tool, and now I think we pay a lot of lip service [to it], but I don’t know that we necessarily carry it from its place in the curriculum to its place in the clinic or the hospital.

But there’s no question that it’s gotten worse [although] the technological advances are just so incredible. I remember at some point, as a student, you have this idea that the CT scan will give the answer, or the lab result will give the answer. The patient’s story is secondary. And I remember some instructors saying, no, no, wait a minute, you should know 80% of the time what the answer is before you even request the test. The test is not meant to be, the be-all, end-all of everything, but, definitely, that is the case now. Even within practice, every advancement that happens in technology kind of nudges us closer to thinking of the computer as a solution for everything.

Let’s say, one patient comes in with chest pain or nausea. I think the tendency now is to focus on those symptoms, to think of what disease might cause them, and to do various tests, rather than sitting down with the patient and trying to understand what their situation is.

You would use less technology if you had a better understanding from interviewing the patient and understanding their situation. And you would have developed a better trusting relationship with the patient, because you’ve expressed your concern about them as a person, not necessarily about their nausea and chest pain solely.

DAVID HSU: You mentioned this earlier, and I wanted to follow up on this little comment you made about how the practice of humanities and writing has a self-care component to it, and that as you’ve practiced it more, it’s helped you handle stress and different challenges. Can you elaborate a bit about this?

JACK COULEHAN: As a high school, college, and even a medical student, I had this inexplicable urge to write poetry, which I did. It’s pretty juvenile. But anyhow, I did it. Then of course, I gave it up because I was a doctor. I was practicing, I was doing research, etc. And in my mid-40s, I was reaching, I think, what you might call burnout. That might be a little too dramatic, but I felt that there was something missing in my life, in my career, and I happened to have a patient who was a professor of poetry at the University of Pittsburgh, where I was teaching at the time. And one thing led to another, and she encouraged me to start writing again. And I did, and I found very quickly that by writing about…my experiences in medicine, I was able to…work through them and understand my reactions better, and so I think that poetry is a reflective practice that in a sense provides occasion for you to grapple with experiences, issues that have been troubling you, or that on the other hand have been very happy. It can work both ways.

Getting back to medical humanities, I think what we’re trying to do in medical humanities is to stimulate that kind of process in young physicians or young clinicians, whether it’s through poetry, through writing journals, through just meeting in small groups…that kind of thing…and to use not only personal experiences, but literature, poetry, film, etc. as stimuli for that.

DAVID HSU: Let’s wrap up with what you would like to see medhum.org do? How would you like to see it grow in the months and years to come? What type of topics or articles do you want us to tackle?

JACK COULEHAN: I like the concept of being provocative. I’d like to encourage people to come in through material that’s kind of leading edge. I’d like to see people have conversations, comments and so on.

DAVID HSU: Thank you, Jack for participating in “Meet the MedHum Editors.” It’s been a pleasure to speak with you.

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Inside The Pitt: Medicine Meets Drama

Dave Hsu — Wed, 03 Sep 2025 11:20:07 +0000

Apollo On Call

This month on Apollo On Call, I sit down once again with our pop culture expert, Dr. Stuart Harman, to discuss our impressions at the completion of season 1 of HBO Max’s medical drama, The PITT. Some of you may remember that Stu and I did a discussion about The PITT a few months back, shortly after the show premiered. At that time, we had only watched about half of the episodes. Now, having completed the entire first season of the show, we are ready to discuss the entire season of the show, with spoilers.

So, if you still haven’t seen The PITT and you’re the type that doesn’t like to have plot developments spoiled, stop right here, go back and watch the show before you listen. For everybody else, enjoy the show!

READ TRANSCRIPT FROM THIS EPISODE

One Patient, Two Systems

Dave Hsu — Mon, 24 Feb 2025 13:50:49 +0000

A Chinese City Doctor’s Notebook–Chapter Two

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary.

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two.

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her?

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop.

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year.

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.”

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding.

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees.

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family.

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away.

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations.

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out.

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system.

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring.

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do?

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope.

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s.

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months.

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week.

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect.

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China?

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that.

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis.

“In Hong Kong, doctors prescribe us antibiotics whenever we want.”
“In China, the doctor would have given us IV fluids for this.”
“In Taiwan, I can have an MRI for whatever body part I want.”

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct.

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months.

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital.

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated.

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution.

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home.

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences.

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients.

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue.

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not?

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week.

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention?

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East.

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here.

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants.

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on.

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went.

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China.

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better?

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada?

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada?

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada.

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language.

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years.

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here.

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada.

Web photo by Zac Ong

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours

01.12.26 551

From Tigers to Otaku

09.16.25 1362

The Happiest Couple

07.28.25 1143

The Things We Don’t Talk About When We Talk About Dying

05.13.25 1724

One Patient, Two Systems

02.24.25 2355

What’s Negative about Negative Capability?

Jack Coulehan — Mon, 25 Nov 2024 19:28:30 +0000

On December 21, 1817, John Keats wrote to his brothers George and Tom about a literary discussion he had recently had with the critic Charles Dilke, after which “several things dove-tailed in my mind.”¹ Keats continued,

“At once it struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously — I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable searching after fact and reason.”¹

The young physician then went on to cite Samuel Taylor Coleridge as a poet whom he considered deficient in negative capability because he was “incapable of remaining content with half-knowledge.”¹ What exactly did Keats mean? That Coleridge was too curious or too intellectual to be a great poet? We’ll never know because Keats, who died of tuberculosis less than four years later, never referred to negative capability again, either in his letters or other writings.

A single mention in a private letter is not much of a pedigree. Nonetheless, Keats’ casual turn of phrase has generated plenty of writings by others in the centuries that followed. Literary critics generally interpret negative capability to mean being open to the world without having preconceived theories, a willingness to suspend judgment, and/or the ability to function imaginatively in the face of incomplete knowledge (e.g. uncertainties, mysteries). In recent decades notable psychoanalysts and philosophers have championed the importance of negative capability in their own fields. In fact, with the enthusiasm of a dilettante who knows little about literary criticism, I’ve gone so far as to argue that negative capability is an important quality for clinicians to develop.²

Wait a second! There’s something wrong with this picture. Physicians not “searching after fact and reason”? Doctors “remaining content with half-knowledge”? How can negative capability be a positive quality in scientific medicine? It sounds negative for sure, but not very capable.

What did John Keats have in mind when he invented the term? In 1816 he had successfully passed his examination for a medical license and joined the Worshipful Society of Apothecaries, yet had also become increasingly ambivalent about a career in medicine. By late 1817 he and his brothers had rented a house in Hampstead, where John devoted himself to writing poetry, as well as taking care of Tom, who was dying of tuberculosis. Keats had given up the idea of practicing medicine. Yet could medical training have had any influence on his concept of negative capability?

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, medical knowledge, or even logical deduction—with all due respect to Sir Arthur Conan Doyle and his teacher, Dr. Joseph Bell, who served as the model for Sherlock Holmes. When I was a medical student, my teachers referred to this quality as clinical intuition or clinical judgment. Yet the word “intuition” was always suspect because it smacked of mysticism, and “judgment” was co-opted in the 1970s by clinical epidemiologists, like Alvan Feinstein, who characterized it in mathematical terms of probability and utility, which sounded good but didn’t capture the experiential quality of medical thinking.³

In an episode of “Star Trek,” when Spock questions Captain Kirk about an apparently foolhardy decision that has endangered the entire crew of the USS Enterprise, Kirk replies, “It’s not logical. It doesn’t make sense. It’s my gut feeling!” Kirk, as usual, had chosen the right course of action and by the end of the episode saves the day. However, even if clinical judgment can’t be reduced to an algorithm, surely it must have more going for it than gut feelings. I recently found an interesting, and I think plausible, definition in the nursing literature: “a judgment in which visual and verbal cues are so rapidly and subliminally observed that their contributions to the final decision are virtually forgotten.”⁴

Yet visual and verbal cues can’t stand alone. They require something to integrate them, a process, a creative spin. Some years ago Edward de Bono coined the term “lateral thinking” for an indirect approach to problem solving, involving ideas that might not be obtainable by using traditional step-by-step logic. (Parenthetically, I imagine that for de Bono the more traditional approach to problem solving must logically be entitled “medial thinking, i.e. closer to the center, whatever that means.) De Bono’s lateral thinking seems roughly equivalent to today’s favorite metaphor for creativity, “thinking outside the box.” Alternatively, those of us who slavishly adhere to reason are doomed to remain trapped inside the box, like Schrödinger’s cat, neither dead nor alive.

Whatever you call it, I find something attractive about attributing a special openness and curiosity to the art of medicine, an openness that permits a greater variety of information to enter the box, rather than kicking the logical brain out of it. In his famous turn of phrase, Keats obviously chose to give “negative” a beneficial meaning. Negative in this context implies passivity, receptivity, and humility , yet it seems these qualities are precisely what made the difference between a competent poet like Coleridge and a truly creative one. Does this sense of negativity have a place in the art of medicine? Does it tell us anything about the difference between merely competent and master clinicians?

One aspect of the comparison fails immediately. Unlike Keats, whose primary goal was beauty, physicians are heavily invested in truth. So “searching after fact and reason” is the name of the game in medicine, not the road to mediocrity. But other aspects of negative capability seem more promising. What if you view negative capability as intellectual and emotional openness, a willingness to be reflective and mindful about one’s practice? While “reaching after fact and reason” may be a defining feature of scientific medicine, clinicians confront a human reality that remains opaque, even after machines and lab tests have yielded their results. If we as clinicians predicate our care entirely on “irritable reaching,” or abandon patients because of “uncertainties, mysteries, doubts,” we lose much of our effectiveness as healers.

I like to think of negative capability as the gateway to reflective practice. In self-awareness or reflective practice sessions, I often prescribe a judicious application of poetry, sometimes even asking students to write a poem about a clinical experience that is particularly meaningful or upsetting to them.

Of course, poetry is only one of many tools that can assist us in developing the habit of reflectiveness, but for me it offers a glimpse into the paradox of the art of medicine: the ability to function at the interface between detachment and engagement, steadiness and tenderness, resilience and vulnerability, science and art. In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients—and with ourselves. In an address to medical students at McGill University, William Osler claimed,

“Nothing will sustain you more potently in your humdrum routine… than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.”⁵

That “power to recognize the true poetry of life” is a function of negative capability. Notice that Osler speaks of sustaining the physician through the “humdrum routine” of professional life, not specifically of patient benefit. Could it be that physicians who develop negative capability are happier, more productive, less likely to burn-out?

I’ll end with an example close to home. In my narrative medicine elective at Stony Brook, I used to ask students to keep a clinical journal. In one of her final entries, one fourth year student, reflecting on her experience in medical school, wrote, “The practice of medicine is simply poetry in motion. The art of medicine is the validation of everything that makes the human experience. I learned more about myself than I ever imagined….”

Simply poetry in motion.

I wonder what John Keats, who rejected medicine for poetry, would have to say about that?

References

Keats J. The Complete Poetical Works and Letters of John Keats, Cambridge Edition. Houghton, Mifflin and Company, 1899, p. 277.
Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389.
Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967.
Cioffi J. Heuristics, servants to intuition, in clinical decision-making. J Adv Nurs 1997; 26: 203-8.
Osler W. The student life. In Osler’s ‘A Way of Life’ & Other Addresses With Commentary & Annotations, eds. S Hinohara and H Niki, Durham, Duke University Press, 2001, pp. 305-330.

Web image from Keats Letter Project.