History of medicine, May 20th 2021
Prof. Mangione
Elvira D’Aronzo, Martina Scopigno, Maria Raffaella De Donno and Alessia Taggiasco
So, this medical student is writing: “... I’m currently on a pediatric rotation at a clinic in
Wilmington, DE. There is a wall where families can pin photos of their young children lost to
gun violence. We speak at length on a day-to-day basis on the circumstances these patients
were born into. We often ask ourselves if what we do makes much of an impact. For
teenagers, we will check A1C and run routine urine screenings for gonorrhea and chlamydia,
but we do wonder if that really matters when the 15-year-old tells us he drinks a pint of vodka
every Friday because he doesn’t know how much longer he’ll live and wants to enjoy his
time while he is still here.
There is no medical fix for that, no treatment we can look up for on UpToDate or in a
pediatric textbook. Oftentimes, we accept the patient’s decision and to make them aware that
they can make those choices while doing the most to keep themselves and those around them
safe.
I hope to continue amplifying the voices of those who often feel drowned out while holding
elected officials accountable for the change they claim to agree with…”
The reason why I’m bringing this up is because a dean of the University of Pennsylvania
Medical School in 2019, just before COVID exploded, wrote an editorial in the Wall Street
Journal saying “That’s not what physicians do”.
“We do not need to teach medical students about gun control, climate change or social justice,
we need to prepare them as physicians and physicians are people that fix bodies”.
Immediati, the American College of Physicians said “That’s what doctors do” and the reason
why they said that is because they had published a paper on the need for gun control in the
US and that paper caught a lot of attention of the NRA that said “Physicians should stay in
their lane”.
Think about that: Is this an issue in which physicians should get involved in?
Anyway, a doctor replied: “We are not anti-gun: we are anti bullet hole in pur patients”.
So this is the issue: Is that part of the responsibility and job description of the physician?
I believe so, but what is a doctor?
This is important, because COVID has reminded us that social issues are huge for health
care.
If you don’t have good leadership you are gonna die. If you don't have good heart care you
are gonna die and there are many social and racial factors that will determine whether you die
or not.
In the US, if you are black or hispanic you have more chances to die because of COVID, or
you have three times the normal chances to be killed by the police. These are racial and social
issues.
Should physicians get involved?
The New York Times even said that racism is a public health emergency.
So my point is that if you are trying to make the world a better place, which is what being a
physician is about, you can make much more of an impact through the stroke of a legislated
pen than through all the stethoscopes and tools of this world. However, we are not trained for
that.
In the US, George Washington University in Washington D.C. sends medical students to
Congress
for a month to work with congressmen and learn how to make an impact.
But our problems are becoming global: “None of us is safe until all of us are safe”. How can
Europe be safe even with vaccines if India and Brazil keep producing variants?
We need good leadership and we didn’t get it in the US. Trump was responsible for the death
of 400.000 people.
So, should physicians get involved?
First of all, the job description is important. I got into medical school but maybe I don’t really
know what a physician does other than fixing bodies.
What is a doctor?
We are NOT providers. What’s the history behind it?
When the Nazi took over, half of the physicians where Jews and that’s when Hitler
immediately demoted them. There were no physicians anymore, they were providers, then
they were sent to Auschwitz. So this term has a horrible connotation.
When I went to the US in the 1970s as an Italian medical student and I fell in love with
American medicine, the term was never used in med articles. But, in the time Reagan
became president, it reappeared and then exploded and started to be used also in articles and
by many journals. It’s a problem of language, language is more than a way of
communicating, as we understand from this quote:
“ I speak Spanish to God, Italian to women, French to men and German to my horse”.
Charles V, Holy Roman Emperor
Language is a reflection of the character of the people that produce it and in Italian do not
have a rule for privacy, we had to adopt it from English. We have 44 ways to say coffee and
that says a lot about Italians.
Hitler knew a lot about language so that he created an entire new language to confuse and
equivocate. Words changed by Hitler (in the pic).
Orwell was fascinated by it. When he wrote 1984 he created newspeak: “War is peace,
freedom is slavery and ignorance is strength” to best confuse people.
In medicine we also have a language to confuse. At least, when medicine is a business and
you have a medical industrial complex you have to equivocate a lot.
Some of these terms may be “Customer satisfaction”, “Stakeholders”, “Templates”,
“Burnout”, “Wellness”…
Paul Krugman writes in the New York Times: “Patients are not customers”.
We are not providers, so what are we?
The importance of the doctors lies in the Latin roots of the name: doceo which means “to
teach”.
We are teachers and healers.
What are the ingredients that make us healers?
A fellow Italian, from the area around Salerno, Edmund Pellegrino, wrote an article 50 years
ago about what makes the idea of physician.
He wrote:
Competence (Techne)
Compassion (Sympatheia)
Culture (Paideia)
What do we mean by culture?
Osler was the symbol of the healer and delineated four basic traits of medicine: “First, the
emancipation [...] from the shackles of priestcraft and of caste; secondly, the conception of
medicine as an art based on accurate observation, and as a science, an integral part of the
science of man and nature; thirdly, the high moral ideals, expressed in that most memorable
of the human documents’, the Hippocratic oath”.
The guy who reformed American Medicine, Flexner, pointed out that as doctors we need
science paired with humanities to remember our ethical responsibility. Hence, we need to be
educated people.
Carl Sagan, before dying of cancer, wrote towards the end of his life this book on science
being a candle: it can still light the
darkness.
He wrote: “Science is more than a body
of knowledge; it is a way of thinking.
I have a foreboding of an America in
my children’s or grandchildren’s
time—when the United States is a
service and information economy;
when nearly all the key manufacturing
industries have slipped away to other
countries;
when
awesome
technological powers are in the hands
of a very few, and no one representing the public interest can even grasp the issues; when
the people have lost the ability to set their own agendas or knowledgeably question those
in authority; when, clutching our crystals and nervously consulting our horoscopes, our
critical faculties in decline, unable to distinguish between what feels good and what’s
true, we slide, almost without noticing, back into superstition and darkness”.
Martin L. King put it simply: why do you go to school?
To gain critical thinking. We know now that 45% of college students in the US lack critical
thinking and more importantly the lack of wisdom.
So why is humanities important? Because of empathy.
There has been a survey conducted in different American schools: USF, Tulane , Portland,
Brown University… and they basically measured every single trait, whose absence will
amend in today’s medicine: empathy, tolerance of ambiguity, wisdom, emotional appraisal. If
the students had more humanities in their schedule, got high results in all of the above.
They were more resilient, more empathetic and wiser.
Antony Fauci graduated in classics, Bernard Lawn was a classics major (he won a Nobel
prize) and Rudolf Virchow spoke seven languages and wrote more papers in anthropology
and archeology than medicine.
We need to be polymath, we need to be eclectic.
Lastly, you need a sense of social responsibility. We take an oath, in which we say “I remain a
member of society” so medicine comes with social responsibility.
This is our job description and we need to keep that in mind to make the world a better place.
I’m saying that because we have a margin of 20 years, otherwise we will be finished.
The President of the UN has said: “COVID is just a rehearsal for what is coming”.
What is the alternative? Indifference, the same mentioned by Dante in the Inferno.
Ignavi: the damned people forced to run after a banner, cause they never took a position.
Indifference is complicity and Martin Luther King says : “The ultimate measure of a man is
not where he stands in moments of comfort and convenience, but where he stands at times of
challenge and controversy.” ― Martin Luther King Jr.
So should we become leaders?
Virchow was a leader, he wrote “Omnis cellula et cellula'' telling us that all the cells come
from other cells and that there is no such thing as spontaneous generation.
The humoral theory is finally dead because, as we know, it existed for a long time. Poor
Giuseppe Mazzini had leeches put on his body because of this theory.
Virchow was also politically involved, he died because he threw himself from a tram, broke a
leg and died because of complications.
He belonged to a poor family, his dad had financial troubles.
He was a bright kid, top of his class. The title of his graduation thesis foretells a life of social
conscience and hard work:
“ A Life filled with told and work is no burden, but a blessing”.
He does not have money, so he joins the army and the military medical school of Berlin and
there he studies a lot.
He writes: “... So it goes unceasingly every day from 6 AM to 11 PM except Sunday, and
how rapidly the days and weeks fly you can see for yourselves. One becomes so tired that in
the evening he sets his eyes toward the bed eagerly, from which he rises in the morning as
tired as if he had slept in a half lethargy”.
But, he finds the time for extracurricular activities: Arabis poetry, learns Greek, French, and
teaches himself Italian. He gets interested in archeology, anthropology and politics.
He tells his father that he wants to acquire a universal knowledge of nature. His father thinks
he is arrogant, but he responds “real knowledge is conscious of its ignorance.”
And then he writes: “... I want to say only this, that in me there is certainly much pride and
egoism, even more in good; also much that is fantastic and dreamy, together with perhaps a
little good. But you misunderstand me if you think my pride is based on my knowledge, the
incompleteness of which I can see the best; it is based on the consciousness that I want
something better and greater, that I feel a more earnest striving for intellectual development
than most other people”.
He discovers three major issues:
1. leukemia
2. trombosis
3. embolism
As soon as he graduated he got a job.
Politically speaking, Germany was not unified, just like Italy and Virchow was a patriot, he
wanted unification. All things blew up in 1848 and because the French were forbidden by
their king to celebrate George Washington’s birthday.
Immediately, the revolution spread to Milan, Venice, Rome, Vienna and then Berlin.
So Virchow was born in Poland, what was happening at that time was an epidemic in the
far-flung province of Silesia (province of Prussia). Virchow was curious to study this
epidemic of typhus.
He realizes very fast that the reason why the poor weavers were getting sick was social.
It’s the environment improper and it’s the government’s fault, the government that pays their
salaries.
He reviewed the history of Silesia:
Being a very pampered, middle-class family, with a buddy on a motorcycle, he sees injustice
for the first time, and he gets radicalized.
That’s exactly what happens to Virchow, that’s why you should travel. You should not travel
to London to get drunk, go to Africa, go to Asia, go where there is injustice, and learn how to
help as a physician.
So he condemns the government, and his prescription is: “Democracy, Education, Freedom,
and Prosperity”.
And he outlines his program:
●
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Tax the rich
Separate church and state
Build roads—> so you can communicate better
Educate the people
Let the Silesian Poles speak Polish
And more importantly, he concludes that “medicine is a social science, and as the science of
man, has a duty to perform in recognizing these problems as its own, and in offering
solutions.”
The answer is culture, with freedom and prosperity.
“Without our notice, medicine has carried us into the social sphere, let us all be aware, we are
talking about treating patients with medications, we are talking about an entire culture of a
million and a half of our fellow citizens who have been physically and morally depraved. The
palliative measure will fail. Only radical action gives hope of success”.
He uses the word radical a lot.
He is becoming convinced that the Germans aren’t going to do that for the Poles, and the
Poles will rebel: “The Poles should fight! And create a Slavic state. And if their lethargy can’t
be dispelled by anything but war, let them fight!
I deeply regret that fire and sword must rage throughout a nation to bring about the necessary
social changes, but mankind has not yet reached that stage in evolution wherein all its
dealings are ruled by reason”.
But where does he get all these ideas that medicine is a social science?
He gets them from Pierre Cabanis. He was a French medical philosopher, a friend of
Benjamin Franklin’s, and he’s the first to say:” Disease is a reflection of societal failure”.
So, Virchow totally buys that, and even more, insists that physicians have to intervene
socially.
“Physicians are the natural attorneys of the poor”
“social problems should be their responsibility”
“Medicine is a social science”.
That becomes his credo for the rest of his career.
Now, just to give you an idea, in the US, 80% of health outcomes depend on social
conditions.
80% depends on whether you’re black, poor, living in a particular part of the country, nothing
else!
How are we supposed to fix it, as the students wrote in the email, without becoming socially
involved?
Virchow has an idea of the state that is very similar to the one of Mazzini.
Mazzini was convinced that we are born to become better and that the job of the state is to
give us the tools to develop our talents, which means two things:
1. Education
2. Healthcare.
When he created the roman republic in 1849, with universal healthcare and universal
education, the most liberal constitution of the times, with women in charge of the hospital of
the capital.
His battle cry is simple: “Improvements in medicine will eventually prolong human life, but
improvements of social conditions can to it faster and better!”.
Once he goes back to Berlin, they have a revolution, and this 5’5 little fellow builds
barricades and he brings his medical students to mend them.
So he becomes the leader and they elect him to parliament, but he’s too young to serve.
So he decides to create a paper, so he can write his own ideas, and he starts insulting people:
● the royalists
● The Catholics
● Anybody who has a religious belief
But he starts getting on people’s nerves, so:
● He gets fired from the Charitè Hospital of Berlin
● They close his paper
The students manage to get him re-appointed, but he has to sign a humiliating statement: “ I
freely pledge that I will not give my political convictions, of whatever nature they may be,
the remotest form of outward expression. This is particularly true of my relationship with the
Charitè, its employees and physicians, and of the lectures I give in the morgue”.
He realizes it's time to get out of town, and when he gets a job in Bavaria, he leaves. And he
writes to his mother: “I regarded it as a civic duty to place myself at the forefront of the
revolution. The king shall have no other will than that of the people. But to achieve that we
need to improve the cultural level of the people. That is the goal of our present endeavor.
Liberty and justice for all!”.
● The first thing he does is to marry a great woman since there is always a great woman
being a great man and vice versa.
● He goes to Wurzburg, Bavaria and he rebuilds his reputation
● In 7 years he Weill write The Book: Die Cellularpathologie in Ihrer Begründung auf
Physiologische und Pathologische Gewedelehre
● And eventually becomes the Pope of medicine
● Then he goes back to Berlin with a vengeance
● Immediately gets elected to city council, which he will be until he dies
● Then he gets elected to the Prussian regional parliament
● Then finally gets elected to the Reichstag after the unification of Germany
● He will serve for 13 years and make Berlin a. Model city for hygiene and health
● He creates a party to piss off Bismark
● Bismark got mad and stated: “politics is to an exact science, I recognize the
prominence of the speaker in his own field of expertise, but since he has amateurishly
stepped out of his field and into mine, I must say that his politics stakes me as
lightweight.
● And to answer, Virchow practically said:” Bullshit!”.
Virchow was convinced that healthcare is a human right and that it should be achieved
through political pursuit.
He is practically the one that allowed Germany to be the second country in Europe to grant
universal healthcare. And they will do it during the war.
England will do it immediately after the war when its economy is destroyed.
All advanced countries quickly progressed towards
universal health care, except one: the United States of
America.
“That’s a form of Communism because no country could
afford those payments without seizing the assets of
everyday else”.
This is nothing new, Ronald Regan said that universal
healthcare is socialist, an insult in the US.
And yet none of those countries are communist, they’re all democracies. But then again, in
the US healthcare is a business, not a right.
Bills
Life Expectancy
The US currently spends the largest amount of money, than any other country that grants
universal healthcare, and has the worst life expectancy.
In fact, 2/3 of American bankruptcies are due to medical bills.
“At the end of the month, it’s either my rent or my medication”. That’s why when Regan
took over, and that’s when they started calling physicians, providers, Leon Eisenberg wrote a
very provocative editorial: “Virchow, where are you now that we need you?”.
Physicians have been part of the problem. This is controversial and Virchow loved
controversy.
Just to give you an idea, when the Germans started getting cocky on race, Virchow did a
study on German school children, to prove that there were as many blond-haired, blue-eyed
Jewish children s there were german, so he became “persona non grata” (not a grateful person
to the nazis) when the Nazis took over.
He remained omnivorously curious and eclectic. He becomes friends with the Schliemann's
and he goes to excavate Troy. He’s the one who comes up with the idea of X-raying
mummies. He’s also a very busy anthropologist, he collects 4,000 kills and uses them to
prove that there is no correlation in a skull between intelligence and race; and of course, he
writes more papers in archeology and anthropology than medicine. He keeps himself busy
with autopsies, and his office is controlled by chaos.
There is a famous story of a young doctor that sent him a paper to be published and never
heard back. So he showed up. Virchow replied that he knew exactly where his paper was and
that he thought it was a good paper and he was going to publish it.
In 1902, after celebrating his 50th anniversary with his wife, the intent of the trolley
happened, and he died.
When Virchow died, he left behind: a wife, 3 sons, 3 daughters, and 19 grandchildren.
But mostly left behind a Country that with him lost its leading pathologist, anthropologist,
sanitarian, and liberal.
In three of those fields, Europe and Germany did very well, it0s just in politics that we went
through civil wars: WWI and WWII. It’s only now, finally, that slowly Europe is trying to
achieve that model of democracy, culture, freedom, and prosperity the Virchow encouraged
us to follow.
“Physicians are the natural attorneys of the poor”. I can tell you I looked up all the
parliaments of Western democracies, and we are very under-represented in Parliament
In the US we essentially don’t exist.
To give you an idea, over the last decade, only 25 physicians served in Congress and they
were not the physicians that Virchow had in mind: they were mostly conservatives, strong
Republicans, against universal healthcare.
One of these physicians is an ophthalmologist who was rumored to be the next Republican
candidate for the presidency.
This is a man who bolstered that masks don’t work, and he actually went around without one.
He had the unique capacity to be the first member of Congress to catch Covid-19, and even
worse, he kept going to committee meetings and the gym while his test was pending, which
means that he infected all of his colleagues.
Talking about us, there are plenty of other physicians that are a disgrace to the profession:
this republican senator who managed to get two physicians, a cardiologist from Washington
and a rheumatologist from Arizona, to testify that masks don’t work, that social distancing
isn’t effective and hydroxychloroquine is actually helpful against Covid-19. All lies.
The question is: Why should we do this?
A physician from Cornell wrote an editorial in the NYT: “when doctors use the language and
authority of their profession to promote false medical information, they are not simply
expressing their own misguided opinion. They have also crossed the line from free speech to
medical practice- or in this case, malpractice.
But where is the outcry from medical leaders and various professional organizations in the
face of this betrayal of public trust? Where was Stanford University when its faculty
members, Scott Atlas were telling Americans that they could forget face masks?”
The problem is that the people that represent us in Congress are not the kind of physicians
that Vircow would have liked:
● half of them are business people
● 1/3 layers, people that are taught how to lie. There is a saying: politicians are people
who had too little morals and ethics to remain, lawyers,
● Physicians are 2.6% of Congress. Just keep in mind that in the US there are 1 mln
practicing physicians, approximately the same number as lawyers.
The physicians that do take part in Congress are republican, mostly men, and 7/11 republican
physicians voted not to certify Biden’s election, which was part of the problem on January
6th in Washington DC.
That’s why there is a paper in “Nature” that says: “Get involved!” The idea that researchers
are political is false! The label “activist” is an honor, not a slur.
European Commission Dr. Ursula von der Leyen is a family physician, and she worked as a
doctor for many years.
She is now a politician, an advocate, and the president of the European Commission.
TERMINOLOGY
In the US, we are all advocates when we pick up the phone and spend an hour with an
insurance company that doesn’t want to pay for the CAT scan of our patient. That’s an
advocate.
But what is an activist? Why is a politician?
Charles Blow in the NYT put it well:
“The politician may be popular, but the activist will rarely be.
The political can unify, but the activist often divides
The politician seeks to unify people around a set of beliefs, the activist seeks to enrich a
wrong that has been held up by a set of beliefs.
In short, the politician navigates the system, where the activist defies it.
The politician builds a coalition by using middling philosophy and policies that appeal to the
most and offend the fewest. The activist is driven more by purpose, morality, and
self-righteousness.
There is a reason most of our greatest activity in America never become politicians: they
would have had to compromise too much of themselves and their causes. But it’s often true
that the presence of an extremist wing is what makes successes of the moderate position
possible…”
Joe Biden is a moderate. Why is he doing what he’s doing you might ask: because there is
humongous activism that pushed him towards the direction, that is why he concluded by
saying: “our moment needs radical young activists”.
Why do we need it?
Let’s speak about a physician that was an activist: Bernie Lown, Nobel laureate for peace and
Inver of the defibrillator.
In his beautiful book, “The lost art of healing”, he writes: “Today’s physical seems to be more
preoccupied with laying tools rather than hands”.
His personal story:
● born in Lithuania, exactly 100 years after Virchow, Lown lost his facility to the
Holocaust.
● His father is a Rabbi
● He leaves when he’s twelve or thirteen and goes to the US
● With this example (his grandfather) before him, Lown spent his life combating racism
and building bridges.
● His lifelong motto becomes: “Never whisper in the presence of wrong!”.
● He studies the classics and goes to Hopkins
● He then goes to Harvard, where he invented the defibrillator
● He refused to patent it, he didn’t want to make a penny out of it. He wanted people to
have immediate access to his invention
● He founds PSR, physicians for social responsibility
● And ultimately: Physicians against nuclear war. He co-founds it with a Russian
colleague and gets a lot of flack from the state department, they call him
“communist”.
● Then they win the Nobel Peace Prize
● The day of the ceremony, during a press conference, a Russian journalist drops dead,
surrounded by cardiologists and the man who invented the defibrillator, they
resuscitate him and Lown immediately says: “We have just witnessed what doctoring
is all about. When faced with a dire emergency of sudden cardiac arrest, doctors do
not require whether the patient was a good person or a criminal. We do not delay
treatment to learn the political views or character of the victim. We respond not as
ideologues, nor as Russian or as Americans, but as doctors. The only thing that
matters is saving a human life. We work with colleagues, whatever their political
persuasion, whether capitalists or communists. This culture permeates our
organizations. The world is threatened with sudden nuclear death. We work with
doctors whatever their political convictions to save our endangered home”.
That could now change with: “The world is threatened with global warming”.
This gave us a good sense that we’re all in this together, and that there are no political
divisions, there are no geographical divisions.
Once again, Merkel put it well: “ the nation-state alone has no future”. We went from the
city-state to the nation-state, and now we are at the threshold of going towards. Global-state,
will we be able to do so?
The reason why this is important is if Bolsonaro is allowed to govern Brazil and to produce
variants through his incompetence it's going to affect all of us.
The four leaders responsible for the worst catastrophes during Covid: Trump (US), Bolsonaro
(Brasil), Johnson (UK), and Modi (India), and three of them even sought it.
Through their incompetence they not only caused a lot of death, but they caused a lot of
variants, that’s why we need to remember that we’re all in this together—> e Pluribus Unum.
How can we make one from many?
Because, as Martin Luther King Jr. put it: “We must learn to live together as brothers or
perish together like fools”
I am convinced that we as physicians have a responsibility, but unfortunately, the public
didn’t behave well in the US.
The first thing we did was buy guns, then resist lockdown, then resisted vaccines and masks
and we stormed the Capitol.
But doctors behaved honorably: we went to protest to get better masks for ourselves, for our
patients, we even went on hunger strikes in Peru.
The surgeon General in the US put it simply:
“People will accuse us of being political, but if people accuse you of being political because
you’re standing up for people who can’t stand up for themselves, then you should do it
anyway because that is at the heart of our profession.”
That’s what Virchow believes, and that’s of course what Bernie Lown believed because
“doctors of conscience have the moral obligation to resist the industrialization of their
profession”.
Lown put it simply: “We go into medicine to make a difference and we are in a unique
position to do so… one cannot be committed to health without being engaged in social
struggle for health”.
He called us advocates for the sick, the poor, and the afflicted.
In the end, we have clout and respect and we should use it to help others, we are natural-born
leaders and Dr. Fauci is probably the best-respected person in America.
Why do we need to do all of this?
Because climate change is coming to get us. Towards the end of his long life, Dr. Lown died
at the age of 99 this February, he was writing about global warming.
Now just read the words of a man who saw the earth from space, and who took this picture:
“The moon’s jagged controls certainly stick in my memory but just barely, compared with the
vision that I summon over and over again of the itsy-bitsy sphere just outside my window,
motionless, cradled in black velvet.
That sight- the Earth, tiny, shiny blue of sky and water, white of clouds, with only a brown
trace of land-haunts me. If I were allowed only one word to describe Earth, I would say
fragile.
We lunar crews looked back at 3 billion earthlings. Almost fifty years later, the number is
almost 8 billion, ever-increasing, with predictions of 10 billion or more by mid-century. This
growth alarms some people, but not too many; they have more pressing problems close to
home.
I wrote in 2009 that we need a new economic paradigm to produce prosperity without
growth. Then years later I believe this even more firmly.”
He was the only man who ever lived to be on that side of the camera, when he took this
picture of Apollo 11, Michael Collins, who was born in Rome, near Piazza Fiume
This is what your generation will have to deal with; and it’s probably one of the reasons why
we had Covid-19, papers have been written on it, and clearly, climate change is altering the
entire spectrum of infectious diseases and health.
If you don’t get involved, we’re finished!
The question now is, will you get involved?
Will we create an international Organization of Physicians Against Global Warming?
We need eclecticism, social responsibility, and critical thinking.
We’ll need a lot of wisdom, foresight and we’ll need science. We’ll need to remember that we
are natural-born leaders, and medicine comes with social responsibility and that we are the
ultimate citizens of the world. We are the only profession that takes an oath of alliance to
mankind and none of us are safe until we are all safe.
Lastly, remember not to be a provider. Try to think highly, idealistically. Which nowadays is
seen as a bad thing. We need a lot of it.
Albert Schweitzer, a Nobel Prize winner writes in his autobiography: “judging by what I have
learned about men and women, I am convinced the far more idealistic aspirations to exist that
are ever evident. Just as the rivers we see are much less numerous than the underground
streams, so the idealism that is visible is minor compared to what men and women carry in
their hearts, unreleased or scarcely released. Mankind is waiting and longing for those who
can accomplish the task of untying what is knotted and bringing the underground waters to
the surface.”
And the reason why we have to do this is that “what we do for ourselves dies with us… but
what we do for others and the world remains and is immortal.” (Albert Pike, 1809-1891)
So this is what moved both Virchow and Lown, and this is the core aspect of the profession.
If there’s a theme to these series of presentations it is to provoke your thoughts about what
kind of doctor you want to be, so I’m trying to demolish this concept that you are going to be
a technician or, as we previously said, a provider. Of course, you are going to be a provider,
since you’ll take care of people, but I’d like to believe, and my dean copyrighted this term, in
Medicine Plus, that being a doctor comes with much more than that. The question is: “What
kind of doctor do you want to be?”, so let me give you some archetypes.
As I told you, medicine got the scientists through the Flexner reform, there wasn’t much
science in medicine because we are talking about 1910. Unfortunately, the result of the
Flexner reform is that humanities got kicked, so the two cultures were separated and what I
think we need is an Osler reform that can put back the humanities.
So, what is a physician? A physician is an artist that uses science, and that is actually Osler.
You need to have this unique combination of the two, you need to be a symphony of
hemispheres, you need the right and the left brain.
Sir Luke Fildes printed this canvas, it is not that big, and is at the Tate Gallery of London.
He clearly painted a doctor, because even though he is not represented with a white coat, a
stethoscope and so on, he is wearing a suit; the doctor is taking care of the baby who has
some sort of infectious illness and the child’s mom and dad are clearly amazed by this man
who is going to stay with the baby for the night.
The guy who painted this canvas had lost his three-year-old son because of scarlet fever and
he was so touched by the fact that Doctor Murray had spent the night with his kid that he
decided to create this painting.
Now, there isn’t much that this doctor can offer, just little concoction, but what he actually
does is mostly giving himself, that’s what a healer is.
Immediately, in 1893, the British Medical Journal wrote: “What do we not owe to Mr Fildes
for showing the world the typical doctor, as we would like to be shown - an honest man and a
gentleman, doing his best to relieve suffering? A library of books in our honour would not do
what this picture has done and will do for the medical profession in making the hearts of our
fellow man warm to us with confidence and affection”.
Now, fast-forward a hundred years, we have a different way of being a doctor (from the
movie “The God Complex):
“The question is, do I have a God Complex?”
“Dr Kessler says yes”
“Which makes me wonder if this lawyer has any idea as to the kind of grades one has to
receive in college to be accepted at a top medical school. if you have the vagus clue as to how
talented someone has to be to lead a surgical team. I have an MD from Harvard, I am board
certified in cardiothoracic medicine and trauma surgery. I have been awarded citations from
seven different medical boards in New England, and I am never ever sick at sea. So, I ask
you: when someone goes into that chapel and they fall on their knees and they pray to God
that their wife doesn't miscarry or that their daughter doesn't bleed to death or that their
mother doesn't suffer acute neural trauma from postoperative shock, who do you think they're
praying to? Now you go ahead and read your bible, Dennis, and you go to your church and
with any luck you might win the annual raffle, but if you're looking for God, he was in
operating room number two on November 17th and he doesn't like to be second guessed. You
ask me if I have a God Complex? Let me tell you something: I am God”
Okay, so, the point is: don’t be an asshole, and by the way, there are plenty of those in the
medical field. But why is Hollywood painting us like that? If you look at this graph, you are
going to see the portrayal of physicians in movies. What has been going on steadily is at the
basement of physicians’ reputation in movies: we are the bad guys. And what has been going
up a lot is the consideration of physicians as jerks with potential, which means that they
really are cold and with a lack of compassion, they are basically assholes, but then they get
sick, and they see the light; that’s how the public sees us in the US.
Technology has separated us from patients, and now with electronic medical records you
spend more time entering data than looking at people. Moreover, we have lost humanities,
which are very important for the connection of which Lewis Thomas, as I’ve told you, wrote
a lot about. Bernard Lown wrote about the fact that the art of healing has been lost and that
we have become a business.
Now you may ask: “But, Dr. Mangione, we just decoded the genome, we have produced a
vaccine against Covid-19 in less than a year, what do they have to complain about?”, and
that’s true, but they don’t trust us as much as they should. Hollywood portrays us as the bad
guys, and frankly folks, we, as physicians, are hurting, we burn out. If you are in the US, and
you are in training, 1 physician out of 3 is going to be clinically depressed.
I have a colleague who eventually got admitted to the hospital and put in a straitjacket, and he
published a reflection on that in the New England Journal of Medicine, he was very
courageous, and do you know what happened to him? He got fired.
So, in the US an average of 400 doctors commit suicide every year, which equals to three
medical classes in the US. As soon as we can we quit… why? This dean, Matthew Duncan,
puts it simply: “We can keep throwing skills at students, but until the culture of medicine
changes, I don’t think we’ll see a big change in burnout”. What I think they are talking about
is the fact that medical school fosters a certain degree of education and cuts out another part
which is what I call the “right brain”, the less linear, the most creative.
So, what’s the model? It is not the Doctor represented in the canvas of Sir Luke Fildes, but
Dr. House, who is clearly a drug addicted, narcissistic, analytically brilliant but not a nice
person or a cultivated gentleman, in fact, a jerk and an uncaring technocrat.
My suggestion is that you need to have a solid humanistic education and then you have to add
the sciences.
As Dimitris Mita stated: “Opera, poetry and Shakespeare are like mumps, and should be
caught when young. In the unhappy event that there is a postponement to mature years, the
result may be devastating”; I wrote something like that in a paper that I shared with Professor
Borghi and I quoted “… 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”, and without that part of
thinking that humanities give you, you wouldn’t be able to be a healer.
I told you how Michael Crichton dropped out of Harvard medical school and, in his
autobiography, he writes: “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”.
Sherwin B. Nuland, the Osler of our time, during a
conference, was asked how to convey wisdom to the
students, and this is how he replied: “If students
applying to medical school do well on the science parts
of the medical college admissions test, that should
automatically disqualify them for going to medical
school. Now, what that means is that we specialize much
too early and without verbally stating so, the educators
responsible for medical education in this country had to
make a decision: was medical school going to be a true
professional school within the University or was it going
to be a trade school. And the answer may surprise you,
those of you who have too much confidence in us: they
came down and decided it was going to be a trade
school. Medical schools are technical schools and I have
visited perhaps fifty or more medical schools in this
country, spent time there, and I have never seen one
where the medical school, even if it is physically on the campus, that is truly part of the
University. Students who go into medicine, at least two thirds of them, have no real education
in humanistic studies, in philosophy, in literature, in poetry, in history of our civilization and
it’s all of these subjects that carry with them everything we have learned in forty-thousand
years of human development. These is what the ideal doctor and the ideal scientist should
know: to understand his or her responsibility to the community; none of us lives long enough
to achieve true wisdom, you just can’t do it, but there is wisdom in these great books, I
deliberately spoke of Aristotle and Ecclesiastes, this is where wisdom can be found. Freud
was fond of discovering the unconscious mind, and philosophers and poets have known about
it forever. This is where wisdom comes from, it comes from a broad cultural education”.
Edmund Pellegrino puts it simply: “Medicine is the most humane of the sciences and the
most scientific of the humanities”.
So, what are humanities? They are wisdom by proxy, because by reading a good novel, by
watching a good play, you live certain experiences that you might not share, but of which you
still acquire their wisdom by proxy, which you will obviously need as a physician.
Medicine is a Rorschach Test, it says more about you than about the profession, you can be
the kind of doctor that you want to be.
And I narrowed the list down to 12 archetypes and we have already analyzed two of them:
the politician and the activist. You can also be a revolutionary, Che Guevara was one and you
can be a Humanitarian. All of these mean care of the other in different ways. Even though
physicians always take care of others, they have to take care of themselves too. For example,
Charles Bell was a painter, Anton Chekhov was a playwright and of course became Anton
Chekhov. Alexander Borotiv, was the dean at the university of San Petersburg, he created the
first medical school for women and role music that hundreds of years later won awards and
you can be a great traveller as David livenston, or a cinematographer. The guy who invented
Italian comedy, Dino risi, was a physician and a psychiatrist who trained in Milan and
Switzerland. They asked him why he quit medicine and he answered: “I couldn’t make them
better so I decided to make them laugh”. You can’t take care of others if you don’t take care
of yourself, that’s how you avoid burnout, that’s how humanity can help you.
I’m now going to talk about three architects:
- The physician as Poet and this is John McCrae ( Also called Jack)
- The physician as a humanist and this is William Osler
- The physician as a philosopher and this is Rita levi Montalcini
Two Canadians and one Italian, and let's start with John McCrae.
He was a poet and poetry means to say the most with the least. We have a tradition of
physicians who were poets and poets make sense because if you think about it Apollo was the
god of both poetry and medicine. Writing is very cathartic and of course as a physician you
have a lot of material to write concerning the human condition. Unfortunately not a lot of
physicians write, we are not trained for that, so we are also storytellers.
John McCrae
John McCrae was borned in Guelph Canada, even though having scottish blood and as a
member of a middle class family, he’s grandfather was a pastor. Being very close to his
brother Tom, both of them became physicians and spent most of their lives together. They
were thought to serve strong ethical Scottish traditions and so part of this meant that around
1893, John became a military cadet winning also a medal. In 1894 he went back to school,
studied the classics and graduated from medical school in 1898. Throughout college he writes
poetry and eventually will write a total of 30 poems that he will publish in a series of short
stories, but he’s also an actor, rugby player and of course an artist/draftsman. All these traits
are very important in enforcing creativity. Coming back to his hometown from his medical
school, the Johns Hopkins university, where he meets Osler, the anglo-boer war develops.
He’s a patriarch so he volunteers and goes to South Africa as a military officer and wins “ the
queen’s medal”.In 1901 he goes back to Montreal and resumes his studies in medicine and
pathology first at Hopkins and then Mcgill. In McGill he gets appointed to the faculty, he’s a
pediatrician pathologist and clinician, he also writes a textbook of pathology for students of
medicine and throughout he’s described as a busy,serious studious and focused but also
sociable man. He loves dogs and horses and children to a point where a man said “
Throughout all his life dogs and children followed him as shadows followed men. To walk in
the streets with him was a slow procession. Every dog and every child one met must be
spoken to”. He continues to write poetry. I'm going to read you the first called “ unsolved”
(1895). (Figure 1)
( Figure 1 )
Translation: He falls in love but then loses her.
McCrae had bad asthma so when he was in college he had to quit a year to take care of it. In
the meantime he taught to high school students at only 20 years old and he lost the women
he was with due to typhoid fever. He never married and most of his poetry is about death. In
fact he is somebody that has a major print of sadness in his poetry and he writes to his mother
“ Perhaps it is because I was brought into nearer connection with death that I think so much
of it”.
Regardless he’s still an adventurous man he goes on to an expedition in the Hudson Bay
where he kanoos for miles and he gregarious “ we traveled three thousand miles and McCrae
had a story for each mile”.
Throughout he keeps in touch with Osler and his brother, and he even proposes to one of
Osler’s nieces however he’s turned down. Then boom Sarajevo, an entire war collapses, he’s
a patriarch, he volunteers but he is in his 40s so he pulls a few strings to finally go. He joins
the military expedition of Canada and they send him to Ypres. After two weeks german’s gas
attacks destroyed the city, the first one being in 1915. Event that inspired the painting below
(figure 2) the john singer Sargent’s “gassed”
( Figure 2)
Painting which, if you go to London, you can go look at, that welcomes the museum and next
to this painting we have word’s by president Kennedy “ either mankind will put an end to war
or war will put an end to mankind”.
So McCrae is traumatised and writes to his mother ( letter below, figure 3 )
(Figure 3)
Promp to the iconic poet at the time of World War 1 was the death of one of his students
Alexis Helmer, who was supposed to get married months later and during a break in the
bombardements he sat by a tree which was bombed in that same range of time. So they bury
him and McCrae catches the drawing of the cemetery where they bury him and that night
after taking care of the wounded, in the dawn sits near the ambulance writes his iconic poem
throughout WW1 named “In Flanders Fields”. The poem is published in the magazine
“punch” and is three stanzas, here it is ( figure 4) :
( figure 4)
The poem is basically a plea by the dead to the living encouraging the living to not die in
vain. Unfortunately that traumatizes him to the point where Harvey Cushing, who is part of
the expeditionary force and his friend says “ since those frightful days he had never been his
old gay and companionable self”. “ Silent asmatic, moody”
Regardless he’s brilliant so he gets promoted to chief of medicine and second in command to
number 3 general hospital at Boulogne, in France. Ultimately he’s further promoted to
consulting physician to the British armies in the Field. Basically he’s the leading physician of
the army and then he gets sick, meningitis and dies in 1918. Cushing is there and goes to the
funeral, they knew each other, they were friends as says: (figure 5)
( Figure 5)
Instead McCrae is buried in France and they give him an important ceremony. His horses on
their backs wore McCrae’s boots as a sign of mourning. But the poem leads on, they use it for
victory bonds, put him on stamps, put his poetry on a 10$ bill and in fact when you go to
McGill university there is this stained glass that says: “to John McCrae pathologist, poet,
physician and soldier with puppies”. They also gave him a commemorative 50$ coin where it
was written: “ he was warm and compassionate with very high principles”. In fact he told his
medical students in Westminster Abbey:”what i spent i had, what i gave, I have, what i saved,
i lost by not giving it”. Which basically pushes them to be altruistic. He proceed to tell them:
( figure 6)
( figure 6)
He died and poppies were used as a sign of mourning, that’s where Fabrizio de Andrei got the
idea of papaveri rossi.
Tom McCrae, his brother, became chief of medicine for 21 years. When he died they gave
him a plaque and a painting reminding how he showed us to be an artist of medicine.
So how come they came like that? they were trained by William Osler ( 1849-1919)
William Osler
Osler is the ideal one to read, so I would urge you to read as much as you can about him. His
father was a minister and Osler was so spiritual that early in life he considered joining the
clergy. (Figure 7)
( figure 7)
He was a humanist and a wonderful person, everybody loved him. By the time he goes to
McGill university he gets a job, and that job makes him a star to the point that at the age of 25
he’s on his way to academic success. The university of Pennsylvania hires him and at the age
of 35 he goes to philadelphia where he will stay 5 years and then eventually he’s asked to go
to Baltimore and becomes the chair of the new department of medicine at the John Hopkins
university hospital. He becomes the model for all medical schools in the usa.
He never missed a chance to remind us that humanities are “ the hormones” of the profession
and how a “ grievous damage” has been done by regarding humanities and science as
anything but “ twin berries on one stem”. Here is what he told his students: ( figure 8 below)
( figure 8)
He used to give to his students at least ten books to read before going to sleep including
Marcus Aurelius,Montain. The last quote is actually a really interesting one, so if you ever
had the experience after an exam that you flunked that you didn’t do well or in the case where
you are sure you did very well, because you know what you don’t know, the one who clearly
flunks is the one who comes out from the test saying “ i did great”, and then you pass by an
arrogant incompetent, worst combination in medicine, so “the greater the ignorance the
greater the dogmatism”.
He was great with kids, great with the old people, he also took care of Walt Whitman and of
course he’s a great clinician.
Some of his students include Doctor Cushing, who single-handedly invents neurosurgery
Osler is the first man that by himself wrote the first book for internal medicine named as “the
principle and practice of medicine” which became the standard for generations to come, it is
still being printed, and he created the first training program in the us. In fact the idea of
research education and treatment is an Osler’s idea.
Then he accepts a job offer in England as Regius professor of medicine at oxford and at 56 he
retires. Unfortunately as soon as he gets to England the wat hits and takes his son. Revere
Osler, the only son William Osler ever had. So let me tell you something about his son.
Revere Osler was serving as an artillery officer near Ypres and in fact during the third battle
he was hit by a shrapnel in the chest and evacuated to a station vin Dozinghem. Now nearby
there is Cushing and they call him in the middle of the night and Cushing goes through a
storm to help out with the surgery. Down in remiscidings is George’s Washington crile (
figure 9) who will go on to found the Cleveland clinic, know a lot about transfusions, so he
gets on an ambulance and they go there and they start the operation at midnight, but they
can’t save him.
( figure 9)
George’s Washington Crile’s writes: ( figure 10)
( figure 10)
Cushing will write a biography of Osler that will win a Pulitzer prize, Cushing writes: “ it
was a strange scene- the great great grandson of Paul Revere under a British flag, and
awaiting him a group of some six or eight American army medical officers- saddened with
the thoughts of his father” because they all knew him.
Osler’s wife writes him ( figure 11 below)
( figure 11)
Osler is heart-broken and he will die within two years. So that’s the biography that eventually
Cushing writes. I’m going to leave you with a few words written by him and we will pass on
to Rita Levi Montalcini. ( figure 12)
( figure 12)
The man who founded the system of the sanitariums in the US put it simply, he said: “ to cure
sometimes, to relieve often, to comfort always” ( Edward Livingstone). But to comfort you
always need philo Sophia.
Rita Levi Montalcini
Rita levi Montalcini wanted to become a philosopher. There is a hostile, useless view towards
philosophers nowadays. False what does philosophy give you? Critical thinking, and critical
thinking in medicine is fundamental. I’m going to focus on one of the twelve women who
won the nobel prize Montalcini, as she was a fellow Italian. Montalcini lived a long life, 102,
she was born when the first plane crossed the channel, she lives in Rome and ultimately does
noble work in Missouri. She goes back to Italy and becomes senator of the republic. She
always wanted to become a philosopher and toward the end of her life she went back to her
first lab and wrote tons of interesting books with beautiful wisdom.
The professor displayed a video with some of her quotes 3 minutes long.
Alright folks, so I'll give you some modules. All of this is in the paper that I told you I sent to
professor Borghi’s.