The stethoscope as metaphor
Until the 1870s, medicine was in fact a spin-off of the humanities. A solid humanistic education was deemed essential for admission to medical school. Then the German victory in the Franco-Prussian War shifted the axis from Paris to Berlin, and medicine went the German way. Never as touchy-feely as the French, and definitely more comfortable in the laboratory than at the bedside, the Germans produced giants like Koch, Virchow, and Roentgen, who gradually moved medicine away from the bedside and into the lab. In fact, medicine even adopted the uniform of the laboratory—the infamous white coat now banned by the British National Health system as a dirty carrier of bacteria.
Finding herself at a crossroads, America went the German way, mostly because of Flexner (himself the son of German immigrants), whose 1910 report totally changed the face of medical education. The “two cultures” were born—science was “in” and the humanities “out.”7
The result is what Lewis Thomas called the “baleful and malign” influence of the modern medical school on liberal-arts education.8 Michael Crichton put it even more bluntly. Explaining why he dropped out of medicine, he wrote, “My classmates [at Harvard] tended to think that literature, music, and art were irrelevant distractions. They held these “cultural” matters in the same intellectual contempt that a physicist holds astrology. Everything outside medicine was just a waste of time.”9
And since then, things have only worsened.10
Yet the link between humanities and the bedside remains crucial. I have had the privilege of meeting most of the clinicians who still contribute to physical diagnosis, and they are almost all humanists.
So why should the humanities nurture the bedside? For one, they may increase our tolerance of ambiguity, a trait sorely lacking in modern medicine. This makes sense, since decoding feeble sounds emanating from chests, palpating indistinct organs, and detecting bedside nuances are all painful reminders of the ambiguous in our craft, not to mention in life. And if unprepared by a humanistic education to deal with the uncertain, students may easily opt for the “certainties” of the laboratory or radiology suite.11 Once again, Osler comes to our rescue.
“A distressing feature in the life which you are about to enter” he told the graduating class of the University of Pennsylvania in 1889, “is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions.”12
The stethoscope is too closely bound with the doctor’s image not to be a metaphor for something larger. To me, it’s a metaphor for medicine as both an art and a science, wherein the humanities are—and of right ought to be—a fundamental part of the education. Hence, if we want to rekindle the bedside, we must rekindle the humanities. After all, this is what both Lewis Thomas8 and Sherwin Nuland13 have urged us to do. My hunch is that this would need to be done sooner rather than later, because if it is possible to make a scientist out of a humanist (it was done for centuries), it might be considerably harder to make a humanist out of a scientist. The experience of the past few decades seems to support this conclusion.
The alternative is a future full of tricorders and technicians, but sorely lacking in healers.
